Evidence-based mental health promotion resource - health.vic.gov.au

Evidence-based mental healthpromotion resource

Evidence-based mental health promotion resource1Evidence-based mental healthpromotion resource

Evidence-based mental health promotion resourcePublished by the Public Health GroupVictorian Government Department of Human ServicesMelbourne, VictoriaFebruary 2006© Copyright State of Victoria, Department of Human Services 2006This publication is copyright. No part may be reproduced by any process except inaccordance with the provisions of the Copyright Act 1968.ISBN 0 7311 6228 5Authorised by the State Government of Victoria, 555 Collins St, Melbourne.Also published on www.dhs.vic.gov.au/healthpromotion/This guide was prepared by:Associate Professor Helen Keleher and Rebecca Armstrong, Research FellowSchool of Health and Social DevelopmentDeakin University, Burwood, Victoria 3127Recommended citationKeleher, H & Armstrong, R 2005, Evidence-based mental health promotion resource,Report for the Department of Human Services and VicHealth, Melbourne.

Evidence-based mental health promotion resourceContentsForeword 1Abstract 3How to use this resource 4Interventions reviewed in this resource 41 Introduction 71.1 Rationale for this resource 91.1.1 Public health significance of mental health 101.2 The focus and purpose of this resource 111.3 Health promotion context 131.4 Understanding mental health promotion 131.5 Health promotion evidence 141.6 Structure of the resource 151.7 Inclusion criteria 161.8 Limitations 162 Determinants approaches to mental health promotion 172.1 Mental health promotion policy 182.2 Determinants of mental health and areas for action 203 Promoting social inclusion and connectedness 233.1 Overview of social inclusion 243.2 Overview of social exclusion 243.3 Overview of social capital and social support 253.4 Overview of interventions to increase social inclusion 284 Addressing violence and discrimination 494.1 Overview of violence and discrimination 504.2 Government policy supporting violence prevention 524.3 Overview of interventions to prevent violence 535 Increasing access to economic resources 695.1 Overview of economic participation 705.2 Overview of interventions to increase access to economic resources 736 Program planning for mental health promotion 876.1 Introduction 886.2 Steps in program planning for mental health promotion 896.3 Useful websites with program planning and evaluation resources 1047 References 105Appendix A: review methods 113Introduction 114Selecting reviews for this resource 115Appendix B: 10 health promotion action areas 121

Evidence-based mental health promotion resourceAcknowledgmentsThis resource has been developed with valuable input and support from Irene Verinsand Lyn Walker of VicHealth and from Susan Heward, Martin Horrocks and MonicaKelly of the Public Health Group, Victorian Department of Human Services, to whom theauthors extend sincere thanks.In addition, the authors thank the members of the expert panel who provided adviceand guidance:Professor John Catford, Deakin UniversityMs Penny Mitchell, University of MelbourneDr John Raeburn, University of AucklandDr Sara Glover, Centre of Adolescent HealthAssociate Professor Lawry St Leger, Deakin UniversityDr Katherine Weare, University of SouthamptonMs Marilyn Wise, University of Sydney

Evidence-based mental health promotion resource1ForewordWe are pleased to provide the foreword to this wonderful resource, which will assistpractitioners as they plan, implement and evaluate mental health promotion programsacross Victoria.Mental health disorders constitute 10 per cent of the global burden of disease. Onein five Australians will experience a mental disorder at some stage in their lifetime. Asthe human, social and economic consequences of mental health disorders and illnessare great, there is also a growing realisation of the serious limitations of focusing solelyon treatment and rehabilitation. Our challenge is to identify ways of promoting mentalhealth and wellbeing and preventing problems before they occur.As mental health promotion is an emerging discipline, the continued development ofevidence to enhance policy and practice, across diverse sectors, is fundamental. Whilsthistorically, health improvements have been attributed only to treatments and medicalservices, there is now indisputable recognition that some of the major determinants ofour mental health and wellbeing lie within the social and economic domains of our lives,and include social inclusion, having a valued social position, physical and psychologicalsecurity, opportunity for self determination and control over one’s life and access tomeaningful employment, education, income and housing.Addressing these determinants to improve mental health requires that manyorganisations from diverse sectors within the community recognise how they canand do contribute to the promotion of mental health and wellbeing. It also requires abroadening of our collective understanding about the range of evaluation methodologiesrequired to measure change in mental health and wellbeing across sectors. It isfurthermore about providing resources and building the skills of practitioners in howbest to monitor and measure interventions in mental health promotion. All of theseactions will contribute to a more robust evidence base, which in turn, will assist withpolicy development and moving the research into practice.The timing of this resource coincides with the government’s renewed focus on adeterminants approach to health. The recently released social policy statement, A FairerVictoria, creating opportunity and addressing disadvantage, strengthens the currentGrowing Victoria Together – a vision for Victoria to 2010 and beyond policy platform andsignals to the field that initiatives targeting mental health promotion are examples ofgood social policy. The recent Victorian Government budget announcements of $124.8million over four years for expansion of mental health programs signals that the newpolicy framework will focus on good mental health and wellbeing for years to come.

2 Evidence-based mental health promotion resourceVicHealth’s Mental Health Promotion Plan 2005–2007 provides a framework formental health and wellbeing and is intended to serve as an information resource forpractitioners from diverse sectors who are seeking to maximise opportunities to promotemental health and wellbeing through their research, policies and programs. Thisprioritisation on the determinants of health recognises the changing environment inwhich we live and reflects the fact that mental health is everybody’s business and thatall sectors, including the health sector, have a role to play in addressing those factorsthat enhance or obstruct mental health and wellbeing.Practitioners are constantly being confronted with more complex issues, which requiresophisticated and multidimensional solutions. We hope that this resource contributesto the solutions and we welcome your feedback and suggestions. We wish you goodmental health as you read it.Dr Robert HallDirector Public Health &Chief Health OfficerPublic Health GroupVictorian Department of Human ServicesDr Rob MoodieChief Executive OfficerVictorian Health Promotion Foundation

Evidence-based mental health promotion resource3AbstractObjectivesTo review the evidence on mental health promotion from determinants of healthapproaches, and to highlight strategies for policy and practice that will strengthenmental health among populations.DesignThe evidence on interventions to promote mental health and wellbeing was reviewedfor effective practice developments.SettingThe resource was compiled for VicHealth and the Victorian Department of HumanServices in 2005 to support the VicHealth Framework for the Promotion of MentalHealth and Wellbeing and the Department of Human Services Common PlanningFramework for Health Promotion.ResultsFinding evidence of what works in mental health promotion is a vast undertakingbecause such a range of evidence can be considered. Given the relative recency ofmental health promotion as a field of endeavour, the extent of programs with strongevidence is perhaps surprising. Many emergent programs would benefit from astrengthening of research design to enable the measurement of more robust outcomes.More established mental health promotion areas can be adapted or replicated locally,either integrated into existing programs or run as stand-alone programs. There is muchscope for health promotion practitioners to include mental health promotion outcomesin a range of programs, and to develop skills and knowledge in thinking about themental health benefits of programs in many sectors and settings.ConclusionsEnsuring communities and populations have the opportunity for good mental healthand wellbeing requires work across individual, community, organisational andsocietal and levels. Mental health promotion is certainly about predicting the possibleeffects of government policy in promoting or demoting mental health, as well as theability of government to provide leadership for public and private sector activity. Atindividual, community and organisational levels, the evidence reviewed in this resourcedemonstrates that there is much that policy makers and program staff can do to activelypromote mental health.

4 Evidence-based mental health promotion resourceMargin notes throughout the resource aredesigned to provide easy access to keyterms and links to supporting documentsand websites.How to use this resourceThis resource assembles an overview of national and international evidence onthe promotion of mental health and wellbeing. Evidence on each topic ispresented as follows:• a short intervention description• the population groups and settings studied• an assessment of the promotion’s effectiveness as it is known• a discussion of implementation issues• additional comments (for some topics).New learnings and promising practices are included as an extra field. They areincluded to account for new information that has accumulated through efforts tobuild up knowledge about what works in mental health promotion but that mightnot have been evaluated to the level of criteria for this resource.• Case studies are located in each section.Interventions reviewed in this resourceInterventions to increase social connectedness1. Community building and regeneration programs p. 282. School-based programs for mental health and wellbeing p. 313. Structured opportunities for participation p. 334. Workplace mental health promotion p. 345. Social support p. 366. Volunteering p. 407. Community arts programs p. 408. Physical activity p. 459. Media campaigns for mental health promotion p. 47

Evidence-based mental health promotion resource5Interventions to address violence and discrimination1. Community-wide interventions p. 542. Community education campaigns p. 573. Programs developed for at-risk populations p. 584. Programs for young people p. 615. Programs for at-risk men p. 626. Legislative and sentencing reform p. 637. School-based bullying programs p. 648. Workplace bullying p. 659. Discrimination prevention p. 66Interventions to increase economic participation1. Adult literacy programs p. 732. Child care programs p. 773. Youth employment programs p. 794. Adult work programs p. 805. Housing programs p. 83Many of these interventions have convincing evidence, while others, on the evidenceavailable, are only promising at this stage. This resource considers existing evidence,but not the many gaps in the evidence base for successful interventions to enhancemental health and wellbeing.The VicHealth Framework for the Promotion of Mental Health and Wellbeing isreproduced here for ready reference. Explanations of framework concepts are providedthrough the resource.

6 Evidence-based mental health promotion resourceFigure 1: VicHealth 2005 Framework for the Promotion of Mental Health and WellbeingKey social and economic determinants of mental health and themes for actionSocial inclusion• Supportive relationships• Involvement in communityand group activities• Civic engagementFreedom from discriminationand violence• Valuing of diversity• Physical security• Self determination & controlof one’s lifeAccess to economic resources• Work• Education• Housing• MoneyPopulation groups and action areasPopulation groups• Children• Young people• Women & men• Older people• Indigenous communities• Culturally diverse communities• Rural communitiesHealth promotion action• Research, monitoring and evaluation• Direct participation programs• Organisational development(including workforce development)• Community strengthening• Communication and marketing• Advocacy• Legislative and policy reformSettings for actionHOUSINGTRANSPORTCOMMUNITYSERVICESCORPORATEEDUCATIONPUBLICWORKPLACEARTSSPORT ANDRECREATIONLOCAL GOVTHEALTHJUSTICEACADEMICIntermediate outcomesIndividualProjects and programsthat facilitate:• involvement in communityand group activities• access to supportiverelationships• self-esteem andself efficacy• access to educationand employment• self determinationand control• mental health literacyOrganisationalOrganisations which are:• inclusive, responsive, safe,supportive and sustainable• working in partnershipsacross sectors• implementing evidenceinformed approaches totheir workCommunityEnvironments which:• are inclusive, responsive,safe, supportive andsustainable• are cohesive• reflect awareness ofmental health andwellbeing issues• value civic engagementSocietalA society with:• integrated, sustainedand supportive policy andprograms• strong legislative platformsfor mental health andwellbeing• appropriate resourceallocation• responsive and inclusivegovernance structuresLong-term benefits• increased sense ofbelonging• improved physical health• less stress, anxiety anddepression• less substance misuse• enhanced skill levels• resources and activitiesintegrated acrossorganisations, sectorsand settings• community valuing ofdiversity and activelydisowning discrimination• less violence and crime• improved productivity• reduced social and healthinequalities• improved quality of lifeand life expectancy

Evidence-based mental health promotion resource 7Introduction 1

8 Evidence-based mental health promotion resourceUseful resourcesFor further information on health promotionpolicy in Victoria, refer to the Departmentof Human Services Integrated healthpromotion resource kit (DHS 2003) andthe website www.health.vic.gov.au/healthpromotion.To access the other evidence reviews andresources in this series, refer to www.health.vic.gov.au/healthpromotion/quality/evidence_index.htm.1 IntroductionThe drivers for health lie outside the health sector.The Victorian Health Promotion Foundation (VicHealth) and the Victorian Department ofHuman Services (DHS) commissioned Deakin University to develop this mental healthpromotion evidence resource, to fill a gap in available resources to advance policy,research and practice responses to the promotion of mental health and wellbeing. Theresource builds on the VicHealth Framework for the Promotion of Mental Health andWellbeing (figure 1). Mental health promotion is an emerging sphere that includesresearch, policy development, community action and program activity. This resourceis intended to develop understanding of mental health promotion and to assist policymakers and practitioners to develop and implement effective interventions in mentalhealth promotion, which is emerging as a thought provoking field of endeavour. Bydrawing together the evidence literature, the resource aims to provide a practicalsummary not available elsewhere, to assist both the integration of mental healthoutcomes into existing program work and the development of programs focusedon the promotion of mental health and wellbeing.Since 2000, DHS has initiated wide ranging reforms in policy and practice to develophealth promotion. Initiatives have been undertaken to develop and implement statewidepolicy to support both quality and effectiveness in health promotion, to therefore buildon the capacity of the service system to plan and deliver effective high quality integratedhealth promotion programs. This resource is number 8 in the series of evidence-basedhealth promotion practitioner resources supported by DHS. The full series is designed tohelp practitioners expand the range of their interventions with greater confidence and witha stronger rationale (based on evidence) than might have been available in the past.

Evidence-based mental health promotion resource91.1 Rationale for this resourceIncreasing attention is being given to the benefits of promoting mental health andwellbeing for populations and communities. The actions taken increasingly rely on apublic health approach that emphasises the importance of the quality of societal andcommunity life. This approach aims to support people to achieve and maintain goodmental health, as well as improve the wellbeing of communities.Good mental health is a prerequisite forgood physical health.Mental and physical health are deeply intertwined and interdependent (World HealthOrganisation 2001). While the need for evidence-based actions to tackle mentalhealth problems is acknowledged, there is growing recognition of the need to betterunderstand and conceptualise how to actively engage in mental health promotion as anintegral part of public health. Further, mental health promotion is often thought to bethe responsibility of those working in the health field, but the determinants of mentalhealth extend well beyond the health sector. The ability of the health sector to influencemental health and wellbeing is thus unlikely to be significant without support from othersectors (Walker et al. 2005). For this reason, greater investment is needed in resourcesthat will assist practitioners and policy makers to develop their skills and knowledge ofmental health promotion.This context of mental health promotion accounts for the mental health of populations(not just individuals) and thus of values, systems, structures and processes thatoperate at all levels of society to promote mental health and wellbeing. Racism,sexism and other discrimination, homophobia, violence and lack of safety, poverty andunemployment, poor employment conditions, lack of access to education and neededhealth services, and lack of support for parents and carers, therefore, are identified asdeterminants of mental health and wellbeing.Good mental health is a prerequisite for good physical health. The uptake of behavioursto improve physical health, including effective self-management of acute or chronicdisease, is intimately connected to an individual’s mental health and wellbeing. Thisresource is built on broad notions of health that recognise the range of social, economicand environmental factors that contribute to health. Health is understood not interms of illness and disease but in terms of people’s capacity to define, assess andanalyse the determinants that influence their health (Labonte 2003), and to accessthe resources they need to act on those determinants. When these conditions are met,people are enabled to adapt, respond to or control the challenges and changes in theenvironments that surround them (Keleher & Murphy 2004).

10 Evidence-based mental health promotion resourceUseful resourcesPromotion and Education: InternationalJournal of Health Promotion and Education2005, ‘The evidence of mental healthpromotion effectiveness: strategies foraction’, Supplement special edition 2,www.iuhpe.org.au.Mittelmark, MB 2003, ‘Five strategies forworkforce development for mental healthpromotion’, IUHPE – Promotion andEducation, vol. 1, pp. 20–2.Further, mental health promotion can be intensely political, given the effects of societywidevalues, systems and structures on people’s mental health, and the implicationsof understanding that governments have ultimate stewardship for the mental health ofpopulations (WHO 2001). Organisations too, have a critical role in supporting mentalhealth and wellbeing. Mental health promotion work may thus include challenges tonorms deeply held within social, cultural and political systems. But not just departmentsof health should be held accountable for mental health and wellbeing:Because many of the macro-determinants of mental health cut across almostall government departments, the extent of improvement in mental health ofa population is also in part determined by the policies of other governmentdepartments...and [those departments] should take responsibility for some ofthe solutions. (World Health 2001, p. 101)This emergent, but still new, paradigm of mental health promotion is moving onto politicalagendas (Jane-Llopis & Mittelmark 2005) as an increasing evidence base demonstratesits place in contemporary health promotion theory and practice.Nonetheless, there is a continuing need for capacity building, particularly inmethodological expertise in mental health promotion to strengthen the evidencebase. Mental health promotion methods need to be strengthened through multi-level,intersectoral, well designed programs that are carefully evaluated for mental healthpromotion outcomes, including organisational change where efforts have been madeto embed mental health and wellbeing outcomes in the work of the organisation. Thisprocess requires a common language about mental health promotion outcomes andan accessible evidence base, both of which this resource seeks to address.1.1.1 Public health significance of mental healthPoor mental health is recognised as a growing cause of morbidity in Australia anda significant co-morbidity of many of the major disease conditions. Mental healthdisorders (excluding dementia) affect more than 25 per cent of the population inany given year (AIHW 2002), causing significant costs to health and economicsystems, with often profound loss of capacity and productivity for those affected.People disadvantaged by chronic illness, low income, unemployment and violenceare more likely to experience mental disorders. In turn, depression is a risk factor forcardiovascular disease, diabetes and cancer, significantly affecting people’s qualityof life (VicHealth 2005a). Women experience higher rates of depression and anxietydisorders than men do, but men experience higher rates of psychiatric conditions suchas bipolar disorder and schizophrenia (AIHW 2002). Mental disorders account for about9.6 per cent of total direct health systems costs and rate about third of the six illnessesor diseases that account for most of the health expenditure in Australia (AIHW 2002).Social factors related to urbanisation, unemployment, poverty, violence, conflict, warand strife, and technological change have had significant mental health consequencesfor populations, with differential effects based on economic status, sex, race and

Evidence-based mental health promotion resource11society. Social isolation, rurality, limited economic and educational opportunities, theabsence of supportive networks and environments, and limited access to needed healthservices are compounding problems for people with mental disorders (World HealthOrganisation 2001).These data demand responses, in terms of not just treatments and service systemsbut also the prevention and promotion of mental health and wellbeing. In otherwords, while the prevalence of mental disorders is compelling in making demands ofresource allocation, mental health promotion interventions occupy an additional space.In addition to developing effective multi-level, longer term strategies, mental healthpromotion interventions affect the prevalence and incidence of mental disorders.Mental health promotion also involves setting the agenda for the governmental andsocietal responsibilities held by all of us. This requires more than just being aware ofthe mental health outcomes of policies, social change and our actions; it means, mostsignificantly, actively promoting policies, social change and actions that will enhancemental health and wellbeing. For this reason, this is a public health agenda that iswide ranging.Useful resourceFor information about the burden of mentalhealth disorders and approaches to buildmental health and wellbeing, see thefollowing VicHealth (2005a) mental healthand wellbeing research summary sheets atwww.vichealth.vic.gov.au:1. ‘Burden of disease due to mental illnessand mental health problems’2. ‘Social inclusion as a determinantof mental health and wellbeing’3. ‘Discrimination and violence asdeterminants of mental health andwellbeing’4. ‘Access to economic resources asa determinant of mental healthand wellbeing’.The mental health plans of both VicHealth and the Australian Department of Healthand Ageing highlight the need for cross-sectoral action in promoting mental health(Commonwealth of Australia 2003; VicHealth 2005a). The creation of good mentalhealth for populations and the promotion of mental health will be more effective ifintegrated closely with all public health strategies and across all sectors around whichsocial life is organised. The involvement of many different sectors, agendas, andpolicies is necessary to strengthen mental health promotion.1.2 The focus and purpose of this resourceThis resource focuses on intervention (or strategy) evaluation of population-basedapproaches to influencing factors that promote or demote mental health and wellbeing.The intention is to assist practitioners to develop effective interventions focused onmental health outcomes, and to emphasise that multi-level and intersectoral actionsare critical for effective program development, implementation and evaluation.The resource identifies and considers key reviews, research and other literaturethat document programs proven to be effective in promoting mental health, and itprovides a guide on how to develop and implement mental health promotion programs.The literature reviewed in the resource has been selected for its relevance to thedeterminants identified in the VicHealth Framework for the Promotion of Mental Healthand Wellbeing, and is informed by a Sydney Health Projects Group literature review(Rychetnik & Todd 2004) that VicHealth commissioned to support the framework’sdevelopment.

12 Evidence-based mental health promotion resourceHealth promotion: a definitionHealth promotion represents acomprehensive social and political process,not only embracing actions directed atstrengthening the skills and capabilitiesof individuals, but also action directedtowards changing social, environmentaland economic conditions so as to alleviatetheir impact on public and individual health.Community participation is essential tosustain health promotion action.(World Health Organisation 1998)Useful resourcesThe Ottawa Charter for Health Promotion(www.who.int/hpr/archive/docs/ottawa.html),written in 1986 at the first internationalconference on health promotion, outlinesa broad definition of health promotion,the prerequisites for health, and threefoundation practices (advocacy, enablingand mediating differing interests). Itperceives health promotion action asnecessary in five areas: policy, supportiveenvironments, community action, personalskills and the re-orienting of health services.The Jakarta Declaration on HealthPromotion into the 21st Century(www.who.int/hpr/archive/docs/jakarta/english.html) was made at the FourthInternational Conference on HealthPromotion in Jakarta. The conferencewas the first to be held in a developingcountry and the first to involve the privatesector in supporting health promotion.The declaration provides an opportunityto reflect on what has been learned abouteffective health promotion, to re-examinedeterminants of health and to identifythe directions and strategies required toaddress the challenges of promoting healthin the 21st century.This resource is intended to strengthen efforts to: promote mental health and wellbeingamong populations, communities and individuals; raise awareness among practitioners,managers and policy makers about the importance of working across sectors; embedmental health into existing and future programs; and build new programs that have aprimary focus on mental health and wellbeing. The following review questions guided thedevelopment of the resource:• Based on current evidence, what strategies for the prevention of illness andpromotion of mental health have been found to be most effective?• What key implementation issues with mental health promotion interventions has theevaluation literature identified?• What innovative strategies currently being implemented and evaluated show promiseof success or are likely to be effective?• What information and research gaps exist in the area of mental health promotion?The action areas of the Ottawa Charter for Health Promotion (World Health Organisation1986) (appendix B) are commonly used as a conceptual framework in health promotionprogram development. This resource uses the VicHealth framework instead to organisethe evidence because it is a more explicit model for mental health promotion thanare the broad action areas of the Ottawa Charter, but connections are made betweenthe two. The resource also connects the VicHealth framework with the Department ofHuman Services (DHS 2003) Common Planning Framework for Health Promotion byusing consistent terminology and identifying its fit with levels of mental health promotioninterventions.Health Promotion Interventions FrameworkHealth promotion interventions and capacity building strategiesIndividual focusPopultation focusScreening, Health Social Community Setting andindividual risk education marketing action supportiveassessment and skill Healthenvironmentsimmunisation development informationEnsuring the capacity to deliver quality programs throughcapacity building strategies including:Organisational Development Workforce Development ResourcesThe Health promotion glossary of theWorld Health Organisation (1998)(www.who.int/hpr/backgroundhp/glossary/glossary.pdf) is a substantial (and useful)document.

Evidence-based mental health promotion resource13Electronic databases, reference lists and the advice of an expert panel were alsoused to identify relevant reviews. This process highlighted that understandings of thedeterminants of mental health, policies and programs for mental health promotion,and methods of evaluation are broad and diverse but yet to be suitably indexed. Inother words, databases are not sensitive to health promotion terms, the determinantsof health or mental health promotion. Nonetheless, our search strategy revealed a wideranging evidence base. Given the breadth of the evidence on a determinants of healthapproach to mental health and wellbeing, this resource is not a systematic review of allrelevant studies.1.3 Health promotion contextHealth promotion is often said to be everybody’s business. In other words, thepromotion of people’s health is a universal concern, understood and supported asrequiring multi-level, multi-sector spheres of action. This resource is consistent withhealth promotion’s universal principles, policies and practices, and its principleframework, the Ottawa Charter for Health Promotion (Appendix B), which takes adeterminants approach to health promotion.1.4 Understanding mental health promotionMental health promotion is underpinned by understandings of what constitutes mentalhealth, but it is often defined at the level of individuals rather than community orpopulation levels. Mental health promotion is frequently located in broad health andsocial development work, and distinguishes population-wide mental health promotionfrom the early intervention and prevention strategies of the mental illness movement.If a determinants approach is taken to defining mental health promotion, then it isnecessary to recognise the importance to mental health of ensuring people can developthe capacity to adapt to, respond to and/or control life’s challenges and changes, andhave the necessary resources to act on the circumstances that determine their mentalhealth and wellbeing.Consistent with health promotion generally, mental health promotion actions need tobe multi-level and intersectoral, and concerned with systems change, policy and thedevelopment of evidence about what population-based programs work. A key messagefor practitioners is that the inclusion in general health promotion programs, of mentalhealth promotion outcomes, will enhance their ability to achieve equity and tackleinequities (Mittelmark 2003; Tilford, Delaney & Vogels 1997). Equity-related outcomesare central to the Ottawa Charter for Health Promotion.Definitions of mental healthMental health is a state of wellbeing inwhich the individual realises his or her ownabilities, can cope with the normal stressesof life, can work productively and fruitfully,and is able to make a contribution to his orher community (WHO 2001,p 1).Mental health is the embodiment of social,emotional and spiritual wellbeing. Mentalhealth provides individuals with the vitalitynecessary for active living, to achieve goalsand to interact with one another in waysthat are respectful and just (VicHealth2005b, p 7).Definition of mental illness and mentaldisordersIn this resource, the term ‘mental disorders’is used rather than ‘mental illness’. Butas this VicHealth (2005a, p. 1) definitionmakes clear, the two terms refer to differentspectrums:Mental illness is a diagnosable disorderthat significantly interferes with anindividual’s cognitive, emotional and/orsocial abilities. Mental disorders are ofdifferent types and different degreesof severity.Definition of mental health promotionMental health promotion contributes togeneral health promotion by taking actionto ensure social conditions and factorscreate positive environments for the goodmental health and wellbeing of populations,communities and individuals. Mental healthpromotion requires action to influencedeterminants of mental health and addressinequities through the implementation ofeffective multi-level interventions across awide number of sectors, policies, programs,settings and environments.

14 Evidence-based mental health promotion resource1.5 Health promotion evidenceThere is considerable debate about what constitutes health promotion evidence.This debate follows the wide acceptance in the evidence-based medicine andepidemiological fields of a hierarchy of ‘rules of evidence’, which are derived frompositivist notions and developed from proof of causation and effect (McQueen 2001).Australia’s National Health and Medical Research Council (1998), for example,identified levels of evidence that particularly apply to medical treatment andinterventions, for which randomised controlled trials and quasi-experimental trialsare the highest standards. Rules of evidence designed for the medical sciences,however, have little fit with the action oriented fields of health promotion, which cutacross sectors and disciplines (McQueen 2001; Petticrew & Roberts 2002).There is no consensus on what constitutes ‘evidence’ in the broad field of healthpromotion, or on the methods of evaluation that provide the strongest evidence base.Typologies of evidence are thus proposed, rather than hierarchies, to indicate therelative contributions that different types of evidence can make to evaluation researchquestions (Petticrew & Roberts 2002). The use of a range of methods, therefore, isadvocated to evaluate critical success factors and outcomes.Evidence is not a stark term; rather, it should be used in terms of ‘weighing up’ thestrength of evidence before deciding on a course of action. Evidence of success couldthus be sufficient to show that action should be taken even when 100 per cent proof isnot available (Tones 1997). In decision making about what works, local knowledge andevidence on applied community-based programs, for example, may be more importantthan evidence that fits with prescribed levels of evidence in the medical–scientificor public health literature. Certainly, there are wide debates about different types ofknowledge, what constitutes evidence, the strengths and weaknesses of differentresearch methods, and thus what comprises robust evidence (Nutley, Walter &Davies 2002). These are debates that cannot be explored here.The task for this resource is to assess the quality of evidence for mental healthpromotion. Given the determinants approach we have taken, that task requires thedevelopment of criteria suitable for multidisciplinary and multi-sectoral health promotionfields of action. Because there is not yet a clear consensus on what evidence to include/exclude for reviews of health promotion interventions, and on what basis, each reviewneeds to establish its own criteria, drawing on accepted wisdom.

Evidence-based mental health promotion resource151.6 Structure of the resourceThe resource is organised into six sections:• Section 1 provides background and introduces mental health promotion as a field ofendeavour.• Section 2 establishes the determinants of the mental health promotion context thatguided the conceptual development of this resource.• Sections 3–5 present the evidence on mental health promotion interventions,organised under the three themes from the VicHealth Framework for the Promotionof Mental Health and Wellbeing: social inclusion and connectedness; freedomfrom discrimination and violence; and economic and social participation. Eachof the framework themes is subdivided conceptually to account for the range ofdeterminants for which intervention evidence was located. Promising interventionsnot yet included in systematic reviews were sought through similar sources, to informthe identification of promising directions for health promotion.• Section 6 provides a guide for program planning and evaluating mental healthpromotion projects. This section links the VicHealth framework with the Departmentof Human Services Common Planning Framework for Health Promotion. As a result,a range of organisations and sectors should be able to translate the resource easilyinto their practice.A consolidated reference list is provided at the end of the resource. Appendix Adescribes the methods used to develop this resource. And Appendix B outlines theOttawa Charter and the Jakarta Declaration for Health Promotion.

16 Evidence-based mental health promotion resourceUseful resourceRychetnik, L & Todd, A 2004, Literaturereview to follow on from VicHealth’s1999–2002 mental health promotionframework: final report, Sydney HealthProjects Group, School of Public Health,Sydney University, New South Wales.Available from VicHealth.1.7 Inclusion criteriaInclusion criteria for this resource were developed on the basis of ‘best availableevidence’. They needed to account for the guideline variations across evidence reviews,particularly to balance differences between guidelines for evidence-based medicine andthe emerging criteria for health promotion evidence. While randomised control trialsin health promotion or public health intervention evaluations are difficult to achieve(National Health and Medical Research Council 1998), criteria are still necessary toprovide a framework of ‘best available evidence’ to support the recommendations.Strength of evidence is linked to quality; it refers to methods used to minimise bias inthe design and conduct of a study. Evidence ‘relevance’ refers to the extent to whichstudy findings can be applied or transferred to other settings, while evidence ‘strength’relates to the magnitude and reliability of the effect of the intervention (National Healthand Medical Research Council 1998). Evaluations that met the following criteria werethus included if they:• were at the level of systematic review• demonstrated clearly defined outcomes in terms of promoting mental health• were published in English between 1998 and 2004• were guided by determinants of mental health promotion.Appendix A contains the search strategy used for this resource, along with theprocesses used for data abstraction.1.8 LimitationsThe complexity of searching for evidence, the need to search multiple databases,the resources available (budget and time), and the emergent nature of mental healthpromotion were key constraints. A further limitation is that evaluations of mental healthpromotion work tend to be of small projects, predominantly using qualitative methodsand focusing on subjective impacts. Assigning quality ratings to evaluations that relyon subjective impacts is exceedingly difficult, and interventions of this nature were onlyincluded if considered to be promising interventions and worthy of wider testing. Moreconclusive evidence is required to make higher level claims about the effectiveness ofsuch interventions. Nonetheless, practitioners are encouraged to use or adapt theseinterventions and conduct careful, thorough evaluations that will contribute to theevidence on effectiveness and impact.The accessibility of health promotion evidence is also challenged by the degree to whichevidence of effectiveness is published and by the ease with which it can be sourced. Asnoted, this resource could not cover the breadth of the topics related to the determinantsof mental health and wellbeing, given cost and time limitations and practical concernswith having an accessible, usable resource rather than a large, impractical volume.The literature review (Rychetnik & Todd 2004) commissioned by VicHealth was thusintended to provide a framework for the review of intervention evaluations.

Evidence-based mental health promotion resource 17Determinants approaches tomental health promotion 2

18 Evidence-based mental health promotion resourceUseful resourcesAustralian Department of Health andAged Care 2000b, Promotion, preventionand early intervention for mental health:a monograph, Mental Health and SpecialPrograms Branch, Canberra.Commonwealth of Australia 2003, Nationalmental health plan 2003–2008, Canberra.2 Determinants approaches to mentalhealth promotionThere is no health without mental health!This section outlines and explains the key elements of a determinants approach tomental health promotion, provides key literature that supports this approach, andcontinues to establish the resource framework outlined in the previous section.2.1 Mental health promotion policyGovernments are the ultimate stewards of mental health, responsible for ensuringresponsible policies, social environments and structures to support the mental healthof populations (World Health Organisation 2001). Both government agencies and nongovernmentorganisations have responsibilities for the development and implementationof policies at appropriate levels. The critical roles of government stewardship ofmental health include the development of policy, the identification of major issuesaffecting the wellbeing of populations, and the defining of public and private sectorroles in developing, funding and implementing policy instruments and organisationalarrangements that meet mental health objectives (World Health Organisation 2001).Policies for mental health and wellbeing can be developed in any organisation,association, club or workplace, and at any level of government. Policy is part of thenecessary infrastructure to support health promotion. Its development involves keyhealth promotion personnel, the development of shared understandings and identifiesthe organisation’s commitment to, and vision for, health promotion. Having policies inplace demonstrates an organisation’s commitment to mental health promotion, whilethe identification of support and resources is motivating for staff.The evidence on the effectiveness of policy for mental health promotion is not yetstrong, because few evaluations of mental health policy are available. This is notsurprising given the difficulties of defining the field, along with the field’s relativerecency. The evaluation of the National Mental Health Strategy in Australia identifiedthat the strategy’s aims have not yet been translated into the benefits expected forthe general population (Steering Committee for the Evaluation of the Second NationalMental Health Plan 1998–2003 2003). Mental health policies should be evaluatedagainst best practice criteria for health promotion generally, and with a clear definitionof what mental health promotion means in the policy being developed.

Evidence-based mental health promotion resource19Australia’s goals and targets of the mid-1990s positioned mental health as a newstrategic direction, with a focus on reducing suicide rates and the effects of mentalillness on people’s lives (Australian Health Ministers 1998). Australia’s first NationalMental Health Strategy was developed in 1992, with both a policy framework and animplementation plan. It was followed by a national community awareness programin 1994 to reduce stigma and discrimination. The second National Mental HealthPlan was launched in 1998 and followed by the National Mental Health Promotion,Prevention and Early Intervention action plan (Commonwealth of Australia 2000).The primary objectives of the 2000 plan were to:Useful resourcesA Fairer Victoria is the VictorianGovernment’s 2005 social policy statementon addressing disadvantage and inequity. Itis available at www.vic.gov.au.T Vinson’s Unequal in life (1999, 2004) is astudy of disadvantage in Victoria and NewSouth Wales by postcode. It is available atwww.jss.org.au.• enhance social and emotional wellbeing among populations and individuals• reduce the incidence, prevalence and effects of mental health problems andmental disorders• improve the range, quality and effectiveness of population health strategies topromote mental health• prevent and reduce the impact of mental health problems and mental disordersamong the Australian population.The National Mental Health Plan 2003–2008 (Commonwealth of Australia 2003) buildson the previous two national plans, to support mental health promotion at a nationalpolicy level. Priority themes for this most recent plan include:• promoting mental health and preventing mental health problems and mental illness• increasing service responsiveness• strengthening quality• fostering research, innovation and sustainability.In Victoria, government is driving a strong agenda to address disadvantage. Its 2005policy statement, A Fairer Victoria, sets out an action plan to improve services andenvironments to strengthen and support communities and their citizens. It takesup themes from policy statements and research from the Jesuit Social Services(www.jss.org.au) and the Brotherhood of St Laurence (www.bsl.org.au).VicHealth is driving a strong policy agenda for mental health promotion in Victoria.This interest in mental health promotion has developed from an emergent evidencebase about mental health and its relationship to the overall functioning of society(Moodie & Verins 2002). The first VicHealth Mental health promotion plan 1999–2002(VicHealth 1999) established a framework for research and program activity to guideunderstanding of mental health promotion from conceptualisation of the determinantsof mental health, through settings and population groups, to expected intermediate andlonger term outcomes.

20 Evidence-based mental health promotion resourceDefinitionA determinant of health is a factor orcharacteristic that brings about a change inhealth, either for the better or for the worse(Reidpath 2004).Useful resourcesHealth Canada has good informationabout the social determinants of health.Its website (www.hc-sc.gc.ca/hppb/phdd/determinants/e_determinants.html#income)introduces the social determinants ofhealth, as well as the ‘made in Canada’principles of health promotion.Marmot, M & Wilkinson, R 2002, Socialdeterminants of health: the solid facts, 2ndedn, Geneva, World Health Organization.Available at www.who.dk/healthy-cities.VicHealth commissioned a literature review (Rychetnik & Todd 2004) to follow the1999–2002 Framework for the Promotion of Mental Health and Wellbeing. The reviewidentifi ed three categories of mental health determinants to guide the literature review:social connectedness, freedom from discrimination and violence, and economicparticipation. and the review addressed two broad questions:1. What published information is available about the identifi ed determinants of mentalhealth and the relationships between the determinants and mental health?2. What is the evidence for potential interventions to address these determinants andpromote mental health?Building on this body of work, the second VicHealth plan, A Plan for Action 2005–2007:Promoting Mental Health and Wellbeing (VicHealth 2005b), was launched in March2005.2.2 Determinants of mental health and areas for actionA determinants approach incorporates understanding how behaviour affects bothsocial processes and disease risk, and how social and structural conditions enhanceor diminish opportunities for communities and populations to be healthy. Suchapproaches highlight the importance of cross-sectoral interventions that are plannedand implemented at multi-levels, with the emphasis on infl uencing one or moredeterminants of health, rather than a disease. The considerable literature on thedeterminants of health identifi es the complex interactions among determinants andacross social, environmental, economic and biological dimensions (Keleher & Murphy2004; World Health Organisation 2003).The 10 element map of McDonald and O’Hara (1998 in HEA 2001) identifi ed positiveand negative infl uences on mental health – those that both promote and demote mentalhealth and wellbeing.Figure 2: 10 elements of mental health – positive and negative influences(Source: McDonald & O’Hara 1998 in HEA 2001.)

Evidence-based mental health promotion resource21To address both positive and negative influences on mental health and wellbeing, fourintermediate outcome levels needing action have been identified (Health EducationAuthority 2001; Health Education Board for Scotland 2001; VicHealth 2005b):1. strengthening individuals: that is, increasing social connection through sustainedinvolvement in group activities, access to supportive relationships, mental healthliteracy (including emotional literacy) and resilience, including interventions designedto promote self-esteem and self-efficacy, self-determination and control, and lifeskills such as communicating, negotiating, and relationship and parenting skills2. strengthening organisations: that is, bringing about change within organisations toensure that they are inclusive and responsive, that they provide safe, supportive andsustainable environments for health, and that they can work in partnerships andacross sectors, and implement evidence-based approaches to their work3. strengthening communities: that is, providing environments that are safe,supportive and sustainable. Communities also need to be able to increase socialinclusion and participation; improve neighbourhood environments; enhance socialcohesion; develop health and social services that support mental health, anti-bullyingstrategies at school, workplace health, community safety, child care and self-helpnetworks; increase citizenship and civic engagement (which affects how peoplerelate to, and deal with, their social world); and increase awareness across sectorsand communities of mental health and wellbeing issues.4. strengthening whole societies, including reducing structural barriers to goodmental health: that is, undertaking integrated, sustained and supported initiatives tobuild the healthy structures and social environments needed to address structuralbarriers to good mental health. This work must occur across sectors, includingeducation, employment, housing, environment and justice. It must have a stronglegislative platform and adequate resource allocation to reduce racism, discriminationand violence, to address inequities and to promote access to education, meaningfulemployment, housing, services and support for those who are vulnerable.Even with these levels of action identified, specific sectors need to clearly understandtheir role in the promotion of mental health. Key sectors that need to act to promotemental health and wellbeing include:• employment and workplace. The availability of work and the conditions of work,unemployment and underemployment are considerable influences on mental health.• education. Basic and lifelong educational opportunities are prerequisites for goodmental and physical health, and key to people’s capacity to find satisfying work,participate in other aspects of social life and undertake social roles.• housing. Adequate shelter is a prerequisite for health. Poor and insecure housing isassociated with poor mental health.• local government. The built, social, economic and natural environments havestrong impacts on mental and physical health and wellbeing. The creation of healthyenvironments to promote good mental health is considered an ongoing challenge.

22 Evidence-based mental health promotion resourceKey documents for health promotion(also see Appendix B).The Ottawa Charter for Health Promotion(World Health Organisation 1986) outlinesthe prerequisites for health, along with threefoundation practices: advocacy, enablingand mediating, particularly betweencompeting interests. It perceives healthpromotion action as necessary in five areas:1. healthy public policy2. supportive environments3. community action4. personal skills5. the re-orienting of health services.The Jakarta Declaration on HealthPromotion (World Health Organisation1997) added five more levels at whichaction should be taken to strengthen health:1. promoting social responsibility for health2. increasing investments for healthdevelopment to address healthand social inequities3. consolidating and expandingpartnerships for health4. strengthening communities andincreasing community capacityto empower the individual5. securing an infrastructure forhealth promotion.• justice. Statutory regulations and policy are necessary to prohibit and reducediscrimination based on sex, race, colour, ethnic or social origin, language, religion orbelief, or genetic features. Equality and nondiscrimination are critical for mental health.• transport. Lack of affordable transport is related to social isolation and diminishedopportunity for employment, education and access to health services.• the arts. Community arts practices have positive mental health impacts through theirimpact on social factors.• sport and recreation. Physical activity improves health. Emphasis is placed onparticipation in sport and recreation, not just competition, and on increasing access.While overlapping, all of these sectors are outside the health sector. In other words,these sectors generate drivers for mental health and wellbeing, so they should be whereprogram activity is focused.The VicHealth framework identified three overarching social and economicdeterminants of mental health:1. social inclusion, including:• social and community connections• stable and supportive environments• a variety of social and physical activities• access to networks and supportive relationships• a valued social position2. freedom from violence and discrimination, including:• the valuing of diversity• physical security• opportunity for self-determination and control of one’s life3. access to economic resources and participation, including:• access to work and meaningful engagement• access to education• access to adequate housing• access to money.These three determinants are used as key organising themes for this Resource,and guided the collection of reviews of key bodies of evidence in mental healthpromotion. The determinants and their sub-categories illustrate concept developmentof interest to this emergent field of endeavour, and their consistency with the OttawaCharter is evident.

Evidence-based mental health promotion resource 23Promoting social inclusionand connectednes 3

24 Evidence-based mental health promotion resourceUseful resourcesAgenda 21 is a comprehensive planof action of the United Nations, to betaken globally, nationally and locally,wherever there are human impacts on theenvironment (www.un.org/esa/sustdev/documents/agenda21/index.htm).Local Agenda 21 in Australia is availablethrough the Australian Departmentof Environment and Heritage(www.deh.gov.au/esd/la21/).Country-wide strategies for social inclusion• The European Union has funded socialexclusion via the European Social Fundand a range of anti-poverty programs.• The Social Exclusion Unit of the UKCabinet Office ensures whole-ofgovernmentcommitment to socialexclusion and its anti-poverty strategy.• The Centre for Analysis of SocialExclusion, London School of Economics,receives substantial funding from theEconomic and Social Research Council.• UNESCO identifies social exclusionas a priority area for research andpolicy through Management of SocialTransformations (MOST).• The World Health Organisation promotesinterest in social exclusion through itsHealthy Cities program and its Disabilityand the European Social ExclusionStrategy (European Disability Forum,1/02). The European Social ExclusionStrategy 2001–2005 contains objectivesfor employment participation, poverty,access to resources, disability anddiscrimination.3 Promoting social inclusion and connectedness3.1 Overview of social inclusionSocial inclusion is a determinant of mental health and wellbeing that is integrally linked tothe Ottawa Charter for Health Promotion, particularly through the action areas of buildinghealthy public policy, creating supportive environments and strengthening communityaction. At one level, it represents the degree to which individuals feel connected withtheir communities; more broadly, it is about the strength within communities andorganisations that sustains positive mental health. Social inclusion is thus a broad notionthat incorporates concepts of social capital, social networks, social connectedness, socialtrust, reciprocity, local democracy and group solidarity (Jermyn 2001).Social inclusion has dimensions of both content and structure. In terms of content, it isabout supportive relationships, involvement in group activities and civic engagement. Itsstructural dimensions are about a socially inclusive society ‘where all people feel valued,their differences are respected, and their basic needs are met so they can live in dignity’(VicHealth 2005a, 1). Mental health is thus a key outcome of social inclusion.Notions of social inclusion and connectedness have origins in European strategies toaddress poverty, particularly the Healthy Cities initiatives. Healthy Cities advocatedadvanced ideas about the structural connections among elements of urban life and thepromotion and maintenance of health, pioneering a range of community interventions.Since its implementation, a range of country-level strategies have explicitly linkedsocial inclusion and exclusion to policy decisions, which also are understood tobe determinants of health and social outcomes. Strategies for social inclusion areconcerned with citizenship, the genuine participation of communities in decisionmaking that affects them, and the creation of supportive built and natural environmentsand policy environments.Some university affiliated programs in the United States have social exclusion andinclusion as a major focus of their disability studies applied research agenda.3.2 Overview of social exclusionSocial inclusion can be understood only in relation to social exclusion. The ways inwhich governments and organisations have taken up social exclusion in forming socialpolicy demonstrate a growing awareness of the global implications, both political andenvironmental, of increases in social exclusion. This agenda concerns the nonmaterialdimensions of poverty because they have enormous economic and social consequencesfor people who may already be living on the margins of communities and society morewidely. Social exclusion is felt through the effects of marginality and inequity on people’sopportunities to contribute and to participate economically and socially.

Evidence-based mental health promotion resource25Poverty essentially refers to economic deprivation, which also carries notions of socialdeprivation and marginality. But poverty is not a proxy for social exclusion. Rather, socialexclusion refers to deprivations that arise from economic deprivation and subsequentlack of material necessities, but also deprivation of opportunity. Sen (1999) interpretedsocial exclusion as the deprivation of capability when a person loses substantivefreedoms that lead to the kind of life that he or she has reason to value. Similarly, theJoseph Rowntree Foundation (2000) identified four dimensions of social exclusion:1. impoverishment, or exclusion from adequate income or resources2. labour market exclusion3. service exclusion4. exclusion from social relations.Populations most commonly identified as vulnerable to, or most at risk of, socialexclusion include those with limited employment opportunities, particularly women,racial and ethnic minority groups, refugees, female and male prostitutes, people livingwith disabilities, people living with drug addiction, people living with chronic illness(including mental ill health), the long term unemployed/underemployed, people who arehomeless, people living in temporary accommodation, young people (especially earlyschool leavers) and older people (especially those living on pensions). For immigrantgroups, language barriers, lack of employment opportunities, and non-recognition offoreign education and work experience reinforce their isolation in a strange culture. Theevidence suggests that the prevalence of illness and mortality increases in individualswho do not feel connected and who feel socially excluded (Kawachi & Berkman 2000;Bunker et al 2003).3.3 Overview of social capital and social supportSocial capital is defined variously, but in general terms is meant to describe theresources available to individuals and to society which are provided by socialrelationships (Kawachi et al. 2002), or as networks that have shared norms, valuesand understandings that facilitate cooperation within or among the network members.Social capital has several key elements (Health Education Authority 2001):• social resources – for example, informal arrangements between neighbours andmembers of clubs or churches• collective resources – for example, self-help groups, community banks• economic resources – for example, levels of unemployment, access to green spaces,community gardens• cultural resources – for example, libraries, art centres, neighbourhood houses,local schools.

26 Evidence-based mental health promotion resourceThe synergy model of social capital identified by Woolcock (2001) has value for mentalhealth promotion work, although stronger research evidence is needed of how thecomponents of social capital can be created and sustained. Intra-community capital,or bonding capital, refers to the intimate relationships and connections among familymembers, close friends and neighbours. Intercommunity capital, or bridging capital,refers to the ties across communities and groups (non-local), but can also refer to localties formed among work colleagues and associates, acquaintances and distant friends.Linking capital refers to the connections among organisations, services and membersof a community, or among groups even if they have differing levels of social status andpower (Putnam 2001). While much scholarship has developed knowledge about howto develop local communities, less is known about how to create networks across andbetween communities, or across difference, in ways that benefit vulnerable people.Social capital and social networks are seen as a resonant measure of communitystrength (Johnson, Headey & Jensen 2003) and as vehicles for turning the tide ofcommunity decline. Changes occur through the regeneration of social and economicbenefits from relationships among neighbours, citizens and governments, which in turnare relationships based on strong norms of trust and reciprocity. Important distinctions,however, are made between theorised and empirical understandings of social capital(Johnson, Headey & Jensen 2003; Stone 2001), and the definitions are much debatedfor their ideological implications.Social capital has societal and structural dimensions. There is wide agreement thatstrong communities and levels of social capital are associated with civic engagement andstronger democracy, improved early childhood outcomes, improved mental and physicalhealth, and improved local economic performance (Johnson, Headey and Jensen2003). There is continuing interest in the concept of social capital, although interventionresearchers of social capital tend to accord greater significance to psychosocialfactors than material deprivation. Yet, income inequality, for example, is critical forunderstanding social capital because it creates stress and damages social capital.Social connectedness and social capital are key determinants of mental and physicalhealth and inequity. People are most commonly connected to family, schools, work anddifferent types of community group, club and organisation. But social connectednessand social capital are not necessarily present in every community, with resulting socialisolation. As determinants, they indicate the need for a progressive agenda fromgovernments to make strategic investments in social and economic development. Thestrength of the relationships between social and structural conditions and mental healthhas been understood for some years, with strong associations made between poormental health and unemployment, poverty, discrimination, social exclusion, violenceand lack of social connectedness. It is not common, however, to see sufficient politicalwill for tackling those social–structural issues to support the promotion of mental healthor prevent mental ill health.

Evidence-based mental health promotion resource27When developing measures of social capital, structure and content need to bedistinguished. The specific activity to which measures are applied needs to beunderstood, as does the level of aggregation to which they are applied; further, thenet benefits of observed social capital need to be assessed (Johnson, Headey andJensen 2003). Social capital is measured at individual and collective/ecological levels(Rychetnik & Todd 2004). At individual levels, it is measured by the number andnature of social networks and social ties (Berkman and Glass 2000). At the collective/ecological level, measures of social capital and social cohesion are used to measuresocial connectedness, social ties and social networks (Berkman & Kawachi 2000).Social connections that matter are considered to be those with family, friends, schools,work, sporting clubs, religious organisations, youth organisations and arts organisations,and in various forms of civic engagement (VicHealth 2005a). When the distinct levelsof social capital are understood and interventions to build or enhance social capital aretargeted appropriately, those interventions are much more likely to be effective.Social support and social isolation are independently associated with mental healthstatus. An independent causal association exists between depression, social isolationand a lack of quality social support, as well as between the causes and prognosis ofcardiovascular disease (Bunker et al. 2003). Berkman and Glass (2000) conceptualisedsocial support mechanisms as:• instrumental and financial, informational, appraisal and emotional• person-to-person contact, close personal contact, intimate contact• access to resources and material goods, including jobs/economic opportunity• access to health care, access to housing, referrals and institutional contacts.Social support can have constraining as well as enabling influences on healthbehaviours, and it is affected by: norms in help seeking and peer pressure; socialengagement; the reinforcement of meaningful social roles; bonding/interpersonalattachment; ‘handling’ effects on children; and ‘grooming’ effects for adults. Alongwith emotional support, it is regarded as an adjunct to material support, particularly toreduce poverty in families with children and to help parents protect their children fromthe effects of disadvantage. It does so by removing barriers to work for parents whowish to combine work with parenting (including child care barriers) and by enablingthose who wish to parent full time to do so (Acheson 1998).

28 Evidence-based mental health promotion resource3.4 Overview of interventions to increase social inclusionThe literature on mental health promotion to promote social inclusion focuseson interventions designed to build social capital, promote community wellbeing,overcome social isolation, increase social connectedness and address socialexclusion. The following list summarises the nine interventions reviewed inthis section:1. Community building and regeneration programs p. 282. School-based programs for mental health and wellbeing p. 313. Structured opportunities for participation p. 334. Workplace mental health promotion p. 345. Social support p. 366. Volunteering p. 407. Community arts programs p. 408. Physical activity p. 459. Media campaigns for mental health promotion p. 47Intervention categories (DHS 2003) used to increase social inclusion include one ormore of the following:• settings and supportive environments• community action• social marketing• health information• health education and skill development.Intervention – Community building and regeneration programsCommunity building and regeneration programs aim to increase social inclusion andtackle social exclusion. In doing so, they aim to enhance mental health and wellbeing.Both place policies and people policies are used. Many governments are developingplace management programs, or local area regeneration/neighbourhood renewalprograms, to address social and economic alienation of people, particularly of thoseliving in urban areas of high unemployment and poor health. People policies focuson benefits, employment programs, community pride, crime and safety, employment,health and wellbeing, housing and initiatives focused on social exclusion in particularpopulation groups. People and place policies supplement each other in waysconsidered to be important but only recently beginning to be understood. Communitybuilding policies and programs seek to combine people and place initiatives.

Evidence-based mental health promotion resource29Population group/settingSettings include local, geographically defined communities as the focus of urbanregeneration or neighbourhood renewal programs. Population groups of interest includeyouth, single parents, elderly citizens and people with disabilities within deprivedcommunities. Community building policies and programs are developing and refiningdifferent approaches needed for rural townships and remote settlements, particularlythose that depend on seasonal incomes or declining industries.EffectivenessEffectiveness is affected if programs are too general and non-specific with ill definedareas of activity. The arguments for and against place-based initiatives should bereviewed before planning commences (Johnson, Headey & Jensen 2003). Planningalso needs to incorporate a review of social benchmarks and indicators (see, forexample, Frankish, Kwan & Flores 2002; Salvaris et al. 2000).There is good evidence of the effectiveness of developing local interventions for specificneeds and groups within community building and regeneration programs, such as thosefor youth, single parents, the elderly and people with a disability (Carley 2002). Thereare gaps in the evidence, however, on the effectiveness of neighbourhood interventionsdesigned to affect social exclusion; models for effective partnerships to improve thedelivery of mainstream services to deprived areas; and effective links between policylevels and programs delivered by various levels of government. In particular, povertyis difficult to overcome at the local level without effective national policies, and keyinstitutional links.Community-wide interventions should be considered at individual, community andorganisation levels (section 2) if they are to be effective. They are broadly cast aspublic health approaches and are best undertaken by partnerships of communityorganisations, government and non-government agencies. In other words, intersectoraland multi-level actions are essential for community building and regeneration programs.These programs are most effective when using a wide range of strategic approachesand drawing on multidisciplinary paradigms (for example, public and environmentalhealth, crime prevention and safety, education and economic development). Strategiesat the community level should be designed to influence one or more determinants ofmental health to reduce unhealthy influences, change unhealthy or harmful events oractivities, or modify social mores at community and structural levels.Building of social inclusion takes many years. The following are best practice principlesand guidelines for area regeneration to build social inclusion:• Multi-agency partnerships are the primary mechanism for area regenerationstrategies – for example, partnerships involving the public sector, private sector andcommunity sector.• Local government is vital and should play a lead role in facilitating and supportingpartnerships, given its political commitment and service infrastructure (Carley2002). Private sector partners, however, rarely make an effective lead partner inneighbourhood regeneration.

30 Evidence-based mental health promotion resourceExample of good practiceThe Beacon Project, a regeneration projectconducted in the United Kingdom, hasidentified impressive health improvements.These have included an 80 per centdecrease in post-natal depression, a 60per cent reduction in child protectionnotifications, a 50 per cent reductionin child accident rates and a 50 percent decrease in the crime rate. Thereis anecdotal evidence to suggest thisapproach has benefited people who aresocially excluded (Duggan & Cooper nd).• Capacity building through skill enhancement is needed to enable effectivepartnerships, and secretariats are required to assist with effective working together.• Programs should pay particular attention to sustainability through the building ofcommunities, so benefits and activities continue after specific program funding hasceased.• Start-up, targeted funding should be used to leverage additional funding from otherlevels and departments of government.• Strategies focused on improving physical capital (housing, open space, transport)are rarely successful if building of human capital through people focused programsis absent (Carley 2002).• In social capital programs, resident involvement in decision making increaseseffectiveness, but effectiveness is reduced if regenerated neighbourhoods experiencea high turnover of residents.Implementation issues• Programs should explicitly address social capital and social connectedness. The UKregeneration initiatives have provided useful learnings and highlighted the need totackle the erosion of social capital.• Measures of social capital should distinguish between the structure of networks (size,internal and external organisational linkages) and their content (trust, reciprocity).Each measure of structure should be matched to one or more appropriate measuresof content (see Johnson et al 2001: 63) in order to specify the area of activity forinterventions;• Programs concerned with rebuilding communities will be more effective if theyspecifically address issues of diversity and equal citizenship.• Programs that identify socio-environmental factors which residents associate withpoor mental health, will enable them to feel some control over decision-makingincluding their influence over neighbourhood decisions, and to identify levels ofneighbourhood social capital in order to address social support and communityaction required.• Mental health outcomes need to be evaluated in order to understand the effect ofthe program. See the VicHealth framework (2005a) and the Catholic Education casestudy (p. 42 below) for ideas.CommentThe Health Education Authority (2001, p. viii–ix) published key recommendations tocontinue developing the knowledge base about effectiveness and to close inequity gapsthrough community/neighbourhood rebuilding and urban regeneration. Rychetnik andTodd (2004) noted that community interventions for neighbourhood or urban renewalundertaken in the United Kingdom and the United States need to be assessed for theirapplicability in the Australian context.

Evidence-based mental health promotion resource31Promising practicesVictoria is in the early stages of developing evaluation evidence for its NeighbourhoodRenewal program (www.dhs.vic.gov.au/neighbourhoodrenewal/). Neighbourhoodrenewal/urban regeneration programs are a relatively recent initiative and thereforeevaluation is (at this stage), limited. They also vary in their focus. For example,Victoria’s Neighbourhood Renewal program (Office of Housing 2005) is focused onsocial and economic exclusion rather than social capital, while other regenerationinterventions are focused on strengthening the resilience and capacity ofcommunities and/or population groups.ReferencesCarley, M 2002, Community regeneration and neighbourhood renewal: a review ofthe evidence, Report to Communities Scotland, Edinburgh Research Department,Edinburgh.Duggan, M & Cooper, A (nd), Modernising the social model in mental health: adiscussion paper, TOPSS, London. Available at www.critpsynet.freeuk.com/duggan.htm.Frankish, J, Kwan, B & Flores, J 2002, Assessing the health of communities: indicatorprojects and their impacts, Institute of Health Promotion Research, University of BritishColumbia, Canada. Available at http://ihpr.ubc.ca.Health Education Authority 2001, Making it happen: a guide to delivering mental healthpromotion, UK Department of Health, London. Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.Johnson, D, Headey, B & Jensen, B 2003, Communities, social capital and publicpolicy: literature review, Melbourne Institute working paper no. 26/03, University ofMelbourne, Melbourne.Salvaris, M, Burke, T, Pidgeon, J & Kelman, S 2000, Social benchmarks and indicatorsfor Victoria, Report for the Victorian Department of Premier and Cabinet by the Institutefor Social Research, Swinburne University of Technology, Melbourne.Intervention – School-based programs for mental health and wellbeingIn Australia, programs have been encouraged to adopt a whole-of-school approach tomental health and wellbeing. Outcomes are sought through resiliency training and byaddressing the issues affecting young people within schools and the broader schoolcommunities (Wyn et al. 2000). Much of this work is based on the concept of healthpromoting schools: ‘strengthening life skills and resilience, fostering a supportive schoolenvironment and a school culture which encourages partnerships between schooland community within a comprehensive program is one pathway to promoting mentalhealth and wellbeing among young people’ (Commonwealth of Australia 1996 as citedin Wyn et al. 2000, p. 595). The World Health Organisation highlighted the importanceof creating an environment conducive to promoting psychosocial competence andwellbeing across the whole school environment (Wyn et al. 2000). This approach seeksto benefit all members of the school community.

32 Evidence-based mental health promotion resourcePopulation group/settingPrograms or interventions are conducted in the school environment with school agechildren and, by extension, the whole school community (including families).EffectivenessEvidence suggests that a schools approach to promoting mental health is likely to bemore effective than focusing on topic-specific approaches (Lister-Sharp et al. 1999),particularly in relation to self-esteem, self-concept and coping skills (Tilford, Delaney &Vogels 1997). Several evaluation studies have identified a decrease in completed andattempted suicide and improvements in attitudes, emotions and coping skills, but theresults about what worked are inconclusive (Gould et al. 2003), so links between healthpromotion programs and mental health improvement require further investment.Implementation issuesPrograms are best implemented at the school community level to engage withstudents, teachers, parents and the curriculum, and to connect with school policy.Promoting school change at all these levels is a recommended vehicle for mental healthimprovement (Lister-Sharp et al. 1999). Where multiple strategies are employed, eachneeds to be evaluated so as to establish the evidence base for which aspects of mentalhealth promotion programs in schools are most effective and why.Promising practicesProgress in the Australian MindMatters project suggests this is a promising approachto mental health promotion and, therefore, the prevention of youth suicide(Waring & Hazell 2002).ReferencesGould, MS, Greenberg, T, Velting, D & Shaffer, D 2003, ‘Youth suicide risk andpreventive interventions: a review of the past 10 years’, Journal of the Academy of Childand Adolescent Psychiatry, vol. 42. no. 4, pp. 386–405.Lister-Sharp, D, Chapman, S, Stewart-Brown, S & Sowden, A 1999, ‘Health promotingschools and health promotion in schools: two systematic reviews’, Health TechnologyAssessment, vol. 3, p. 22.Tilford, S, Delaney, F & Vogels, M 1997, Effectiveness of mental health promotioninterventions: a review, Health Education Authority, UK Department of Health, London.Waring, T & Hazell, T 2002, Evaluation of MindMatters: third interim report, HunterInstitute of Mental Health, New South Wales.Wyn, J, Cahill, H, Holdsworth, R, Rowling, L & Carson, S 2000, ‘MindMatters: a wholeschoolapproach promoting mental health and wellbeing’, Australian and New ZealandJournal of Psychiatry, vol. 34, pp. 594–601.

Evidence-based mental health promotion resource33Intervention – Structured opportunities for participationParticipation provides opportunities for citizens to engage with others and becomepartners in building social life.Population group/settingPrograms target all ages from school aged children to older people, in any communitybasedprojects, including sport or cultural projects (HEA 2001; VicHealth 2003). Inparticular, communities with immigrant groups and cultural diversity benefit fromprojects that focus on participation. Women immigrants are particularly vulnerableto social isolation when they experience barriers to classes in the English language,underemployment, lack of family support, a decrease in social status, and familyconflict, as well as gender issues related to the labour market (Mulvihill, Mailloux& Atkin 2001). Interventions are also developed for men who feel they do not havepersonal support and lack social connections.Program settings include civic structures that encourage engagement via localgovernance, community participation and other forms of social contribution.EffectivenessPeople gain multiple health benefits from opportunities to participate and becomeinvolved. Genuine participation builds local democracy and neighbourhood socialcapital through social connections, as well as feelings of control over decision makingabout local issues. Engaging people to encourage their participation is a form of socialvalidation (HEA 2001; VicHealth 2003).Connectedness can be enhanced by ensuring access to familiar language and culture,connection to social support services and recreational activities, and appropriateorganisation of neighbourhoods and shopping precincts (Mulvihill et al. 2001).Interventions to establish social connectedness of immigrants are usually local andconducted on a relatively small scale without strong evaluation. Reviews have tendedto focus on ‘high risk’ individuals rather than populations or communities (Rychetnik &Todd 2004).Implementation issuesThese programs need to:• identify population groups of interest who experience vulnerability or disadvantage,or social isolation• work with migrant centres and community leaders• ensure high levels of community engagement with all stakeholders• establish social arenas that build connection and trust in multicultural contexts• advance sustainability by:– ensuring processes for skills development– setting up avenues for ongoing support mechanisms– bringing about shifts in community attitudes– creating connections that did not previously exist.

34 Evidence-based mental health promotion resourceExample of good practiceThe Ambassador newspaper, a collaborationof the Horn of African CommunitiesNetwork, Adult Multicultural EducationsServices and VicHealth, is a self-managedenterprise producing a regular newspaperin eight of the languages spoken in theHorn-of-Africa. Produced for and by Africancommunities, it provides information toassist new arrivals to settle in Australia.Those involved reap the mental healthbenefits of the natural social connectionsoccurring through enterprise building andnewspaper production. The skills thatparticipants learn will contribute to thelong term sustainability of the enterprise,as well as improving their prospects ofgaining future employment. By contributingto a positive African Australian identity,the newspaper will also help to build selfdeterminationand self-esteem in Africancommunities.CommentThe growing literature on partnerships and participation is testimony to the increasingvalue placed on these approaches, but program evaluations need to better identifymental health promotion outcomes (Kawachi & Berkman 2001).ReferencesHealth Education Authority 2001, Making it happen: a guide to delivering mental healthpromotion, UK Department of Health, London. Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.Kawachi, I & Berkman, LF 2001, ‘Social ties and mental health’, Journal of UrbanHealth, vol. 78, no. 3, pp. 458–67.Mulvihill, M, Mailloux, L & Atkin, W 2001, Advancing policy and research responses toimmigrant and refugee women’s health in Canada, Canadian Women’s Health Network,Manitoba.VicHealth 2003, Promoting young people’s mental health and wellbeing throughparticipation in economic activities – key learnings and promising practices, VictorianHealth Promotion Foundation, Melbourne.Intervention – Workplace mental health promotionJob or occupational stress is a major public health problem that is increasing inprevalence but is largely preventable (LaMontagne et al. 2005). It is defined asthe combination of high job demands and low job control, and it predicts physicaland mental health problems and mental illness, particularly depression in women,cardiovascular disease, increased absenteeism, employee turnover and worker’scompensation costs. Poor mental health in the workplace is connected to aggression,bullying and workplace violence, precarious work circumstances and job insecurity,and long working hours (LaMontagne et al. 2005).Systems approaches (rather than those focused on individuals) that integrate publichealth/health promotion and prevention approaches (from primary level responsesthrough to organisational change) are indicated as having the most effect in improvingjob stress. Organisations may have emerging capacity to deal with the mental healthproblems of staff, but leadership and guidance on the implementation of integratedsystems strategies are needed (LaMontagne et al. 2005).Employee participation is a key mechanism for mental health promotion in theworkplace. Employee participation programs can involve all level of workers (particularlythose in the lower hierarchy), and they aim to increase involvement in decision makingthat affects the health and wellbeing of workers, provide onsite, peer led training, teachnew skills and strengthen networks (Heaney et al. 1995 cited in Jane-Llopis et al. 2005).

Evidence-based mental health promotion resource35Population group/settingProgram can be implemented in workplaces of all types, particularly for female workers,workers aged less than 30 years who are working long hours (36–49 hour per week),and those employed to use low to middle occupational skill (LaMontagne et al. 2005).EffectivenessOrganisation-wide approaches to employee participation are most effective when theysupport staff involvement, enhance job control, encourage workload management,clarify roles and involve policies to tackle bullying and harassment. Modification ofstressful occupational environments reduces mental health problems among employees(Health Education Authority 2001). A large scale, randomised trial of the CaregiverSupport Program was designed to measure support for caregiver teams in health andmental health facilities. Results included enhanced mental health and job satisfaction,and positive effects on retention (Heaney et al. 1995 cited in Jane-Llopis et al. 2005).Implementation issues• Interventions must be made relevant for the particular setting and must includegenuine participation of staff to ensure empowerment is an outcome. Needsassessment and/or risk assessment is thus strongly recommended to tailorinterventions to the context.• The development of an evidence base on economic outcomes (such as absenteeismrates, costs and benefits) will encourage policy in, and the practice of, systemsapproaches. Job stress intervention research from public health approaches will helpto guide policy and practice in this area (LaMontagne et al. 2005).CommentThis intervention description links with the determinant of economic participation(section 5).ReferencesHealth Education Authority 2001, Making it happen: a guide to delivering mental healthpromotion, UK Department of Health, London. Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.Jane-Llopis, E, Barry, M, Hosman, C & Patel, V 2005, ‘Mental health promotion works:a review’, IUHPE – Promotion and Education, vol. 2, pp. 9–25.LaMontagne, AD, Louie, A, Keegal, T, Ostry, A, Shaw, A 2005, Workplace stress inVictoria: developing a systems approach, Report to the Victorian Health PromotionFoundation, Melbourne.

36 Evidence-based mental health promotion resourceIntervention – Social supportSocial support is regarded as a ‘psychosocial intervention’, which is a general term forinterventions designed to modify behaviour and create supportive environments. Theseinterventions encompass every level, from individuals, the family, social network, theworkplace and the community, through to the population level (Glass 2000). Effectivesocial support interventions include parent training programs for improving maternalmental health (Barlow & Coren 2002) and home-based social support for sociallydisadvantaged mothers (Hodnett & Roberts 2004). Programs such as the multi-countryHome-Start program (Jane-Llopis et al. 2005) aim to increase family confidence andindependence, empower parents, and offer social support through time, friendshipand practical help by volunteers. The multi-country Community Mothers program(Jane-Llopis et al. 2005) focuses on health care, nutritional improvement and childdevelopment.Population group/settingThese programs target mothers of young children, young mothers and early parenthoodgenerally and vulnerable families in particular.Effectiveness• Home visiting by public health nurses or midwives, whether a stand-aloneintervention or part of a multiple intervention, reduces the risk of postnataldepression, improves parenting skills and mother–child interactions, and has animpact on child health priorities such as child abuse, child behaviour, oral health,infant mortality and injury, language and literacy, and parent mental health(Eagar et al. 2005).• Parent training programs are effective in promoting short term psychosocial healthoutcomes for mothers. Evaluations are not at the level of randomised controlledtrials, although long term follow-up of Home-Start families noted self-reported parentsatisfaction that the program made a positive difference to their lives. Significantdifferences between Home-Start families and comparison groups have not yetbeen found.• Randomised controlled evaluation of the Jamaican adaptation of the home visitingprogram showed a dose–response relationship between frequency of visits andcognitive development of the children (Jane-Llopis et al. 2005).• Peer or professional support programs for parents with mental illness have shownencouraging results in reducing stigma and assisting parent–child communicationabout mental illness. Depressive symptoms were reduced and family functioningwas improved (Eagar et al. 2005).

Evidence-based mental health promotion resource37Implementation issuesPrograms from one country need to be examined for their applicability in the contextsand settings of another country. The replication of the Community Mothers Programdemonstrates its ability to be adapted for various contexts, and evaluation demonstratesits potential to be delivered by lay persons.Promising practicesCommunity-wide interventions (such as Victoria’s Best Start program) offering layersor ‘tiers’ of support to parents are promising, although evaluation data are not yetdefinitive (Eagar et al. 2005: ix)ReferencesBarlow, J & Coren, E 2002, ‘Parent training programmes for improving maternalpsychosocial health’, Cochrane Database of Systematic Reviews, 2003, no. 4.Useful resourceHome-Start International is an earlychildhood program with country programsacross the world. Home-Start (Australia)Inc. (www.home-start-int.org/Australia.asp) is an independent, non-governmentorganisation that provides training andsupport for the establishment of localHome-Start programs, either auspiced bya community organisation or managed bya local committee of management. Trainedvolunteers reach out to provide socialsupport to families who are struggling tocope with ill health, disability, poverty andother adversities.Barlow, J, Coren, E & Stewart-Brown, S 2001, Systematic review of the effectivenessof parenting programmes in improving maternal psychosocial health, Health ServicesResearch Unit, University of Oxford, Oxford.Eagar, K, Brewer, C, Collins, J et al 2005, Strategies for gain – the evidence onstrategies to improve the health and wellbeing of Victorian children, Centre for HealthService Development, University of Wollongong, New South Wales.Hodnett, ED & Roberts, I 2004, ‘Home-based social support for socially disadvantagedmothers’, Cochrane Database of Systematic Reviews, 2004, no. 4.Jane-Llopis, E, Barry, M, Hosman, C & Patel, V 2005, ‘Mental health promotion works:a review’, IUHPE – Promotion and Education, vol. 2, pp. 9–25.

38 Evidence-based mental health promotion resourceCase study: the Schools as Core Social Centres initiativeA partnership between the Catholic Education Office Melbourne (CEOM) and VicHealth resulted in the Schools as Core SocialCentres (SACSC) initiative, which was conducted across clusters of schools in Melbourne. This initiative aimed to strengthenevidence of the links between student wellbeing and learning outcomes. A School Improvement Agenda was developedand measured through accountability and measurement tools. The tools support a strategic approach to developing the linkbetween social capital, school/community partnerships and student learning outcomes.The Mental Health Promotion Framework below was developed from the results of the research conducted during the SACSCinitiative, and then modelled into a conceptual framework based on the VicHealth Framework for the Promotion of MentalHealth and Wellbeing. The conceptual framework was developed to inform strategic implementation in relation to:• the role of schools in developing school–community partnerships and social capital• the relationship between the growth of social capital, improved learning student wellbeing and outcomes.SACSC Mental Health Promotion Framework 2005–07Key social and economic determinants of mental health and themes for actionSchool connectedness Social connectedness Community connectedness• Involvement in school activities• Sense of belonging• Supporting relationships• Emotional wellbeing• Involvement in community activities• Access to local resourcesPopulation groupsPopulation groups and action areasSACSC action plan• Students• School staff/personnel• Parish priests• Families• Broader community• Partnerships• Development of audit tools• Development of conceptual framework• Ongoing evaluation• External funding sources• Schools• Local government• VicHealthSettings for action• Community agencies• Catholic Education Office Melbourne• Sport and recreation• Local government• Housing commission estates• Local church/parish• School ethos, culture and environment• Organisational structures• Policies• Decision-making processes andprocedures• DiversityAreas for action• Leadership and governance• Curriculum teachingand learning• Research initiatives• Professional learning teams• Learning styles• School/community partnerships• Professional development• Parent/community participation

Evidence-based mental health promotion resource 39Intermediate outcomesIndividual Organisational Community Schools• Social emotional health• Supportive and caringrelationships• Involvement in school andcommunity activities• Resiliency• Protective factors• Learning outcomes• Student/schoolconnectedness• Positive relationships• Student backgroundand experience• Student engagement• Research circle• Partnership across sectors(Victorian Department ofEducation and Trainingand Melbourne University)• School clusters developed• Professional developmentand learning• Collegiate support• Promotion of best practice• Participation in SACSCactivities• Connectedness• Community projects/activities• Social/cultural inclusivity• Involvement of families• Linking with agencies• Working with the community• Self-determination• Welcoming environment• Community/schoolcollaboration andparticipation• Family/school supportto students• Core leadership teams• Whole school approach• School development plan• Audit tools• Professional learning teams• Access and equity• School-based action research Initiatives• Safe and supportive environment• Participation of school community• Partnerships• Relevant and meaningful curriculum• Democratic schooling• Warm classroom climate• Physically welcoming• School budget allocation• School/community collaborationand participationPopulation groups and action areasPopulation groups• Students• School staff/personnel• Parish priests• Families• Broader community• PartnershipsSACSC action plan• Development of audit tools• Development of conceptual framework• Ongoing evaluation• External funding sourcesLong term benefits• Improved student wellbeing• Increased community participation• Development and growth of partnerships• Placement of social capital and student wellbeing at the coreof school life• Increased access to community groups, agencies and services• Improved learning outcomes for all• Embedding the SACSC initiative across schools in the Archdioceseof Melbourne• Ongoing professional learning and professional development• Development and growth of research initiatives• Evidence-based research to inform systemic school improvement

40 Evidence-based mental health promotion resourceVolunteering Australia (2001) definedformal volunteering is an activity that takesplace in not-for-profit organisations orprojects and is undertaken:• to benefit to the community and thevolunteer• of the volunteer’s free will and withoutcoercion• for no financial payment• in designated volunteer positions only.It noted the following principles ofvolunteering:• Volunteering benefits the communityand the volunteer.• Volunteer work is unpaid.• Volunteering is always a matter of choice.• Volunteering is not compulsorilyundertaken to receive pensions orgovernment allowances.• Volunteering is a legitimate way in whichcitizens can participate in the activities oftheir community.• Volunteering is a vehicle for individuals orgroups to address human, environmentaland social needs.• Volunteering is an activity performedin the not-for-profit sector only.• Volunteering is not a substitute forpaid work.• Volunteers do not replace paid workers orconstitute a threat to the job security ofpaid workers.• Volunteering respects the rights, dignityand culture of others.• Volunteering promotes human rightsand equality.Intervention – VolunteeringVolunteering provides structured opportunities for people to do voluntary work in theircommunity, which is one aspect of civic participation and engagement.Population group/settingVolunteer programs target adolescents and adults of all ages.EffectivenessThere is good evidence that engagement in meaningful volunteer activities increasesfeelings of wellbeing and quality of life and enhances social connectedness, especiallyamong older adults (Wheeler, Gorey & Greenblatt 1998). The training of retired adultvolunteers to deliver pre-retirement programs produced measurable change in selfefficacy,knowledge about retirement and morale (Wheeler, Gorey & Greenblatt 1998).Implementation issuesVolunteers need support to ensure they feel able to sustain their involvement.Sustainability can be advanced by:• ensuring processes for skills development• setting up avenues for ongoing support mechanisms• bringing about shifts in community attitudes• creating connections that did not previously exist.ReferencesVolunteering Australia 2001, Home page at http://volunteersearch.gov.au/.Wheeler, J, Gorey, K & Greenblatt, B 1998, ‘The beneficial effects of volunteering forolder volunteers and the people they serve: a meta-analysis’, International Journal ofAgeing and Human Development, vol. 47, no. 1, pp. 69–79.Intervention – Community arts programsCommunity-based arts projects and initiatives are concerned with communityparticipation, social inclusion, capacity building and regeneration, the building of socialcapital through participation and social connectedness, and health generally. They arealso an expression of civic participation. Arts projects aimed at community participation,capacity building and regeneration are sometimes designed to have health outcomeswith health promotion objectives, but they are more likely to be designed around artsPopulation group/settingA wide variety of social groups (including at-risk groups) are suitable for communitybasedarts projects in diverse settings.

Evidence-based mental health promotion resource41EffectivenessWhile mental health is often an outcome of arts projects, objectives are not usuallystructured around mental health outcomes, so the evidence is more in terms ofoutcomes relating to pleasure and quality of life, and health and wellbeing outcomessuch as ‘feeling better’ or ‘happier’. In urban regeneration programs, arts programshave had a range of community development outcomes, including increasedcommunity identity, reduced social isolation, improved recreational options, thedevelopment of local enterprise and improved public facilities (Jermyn 2001). TheArts Council of England (Jermyn 2001) developed systematic evaluations to measurehealth and wellbeing outcomes from arts projects in settings such as hospitals,neighbourhoods and prisons. But there is little rigorous evaluation of social capital asan outcome of community arts programs. Outcomes related to trust and collaborationinclude group cooperation, effective communication of complex ideas, and theidentification of common goals.Much of the evidence is subjective – for example, appreciation of the value ofcommunity arts, the development of community identity/confidence, and thedevelopment of community networksImplementation issuesHealth and social outcomes of community-based arts programs may seem difficult tomeasure, but the use of a framework such as the VicHealth framework (2005) canassist with planning. Factors thought to underpin success include creative passion,dynamic relationships, experimentation and innovative problem solving. Other successfactors include:• connection with local needs• democratic relationships, which are critical to successful outcomes and includesharing control and adopting flexible and adaptable working methods• good practice frameworks that allow sufficient time for planning, building successfulparticipatory methods and creating robust models for working in partnership• an emphasis on quality and striving for excellence, which creates pride inachievement. An ‘anything goes’ attitude can be detrimental to success.CommentRigorous analysis and long term evaluation of the impact of community arts programson mental health and wellbeing need to be undertaken. The incorporation of short orintermediate term mental health outcomes into community arts projects or programswould be relatively easy to achieve. Evaluations of mental health outcomes from suchprograms would make valuable contributions to evidence about what works.

42 Evidence-based mental health promotion resourceUseful resourcesFlowers, R & McEwen, C 2003, The impactof re-igniting community and ‘The Torch’on community capacity building, Centrefor Population Education, University ofTechnology, Sydney.Mills, D & Brown, P 2004, Art andwellbeing, Commonwealth of Australia,Canberra.The evidence review undertaken by The Globalism Institute (McQueen-Thomson andZiguras 2002) identified that a substantial body of research identifies the positive healthimpacts of community arts practice, but that much of the literature is anecdotal. Toaddress these issues, the review report recommended that projects focus on knowndeterminants of health rather than broad social indicators, focus on participantsand audiences rather than organisers, increase sample size and use longitudinaldimensions. Another recent evidence-based review (Scottish Executive EducationDepartment 2004) also called for longitudinal research.ReferencesCampbell, C, Wood, R & Kelly, M 1999, ‘Social capital and health’, Health EducationAuthority, London. Available at www.hda-online.org.uk/downloads/pdfs/socialcapital_health.pdf.Jermyn, H 2001, The Arts and social exclusion, Review prepared for the Arts Council ofEngland, London. Available at www.artscouncil.org.uk/documents/publications/298.doc.McQueen-Thomson, D & Ziguras, C 2002, Review of the health benefits of communityarts practice, The Globalism Institute, School of International and Community Studies,RMIT University, Melbourne.Scottish Executive Education Department 2004, A literature review of the evidence basefor culture, the arts and sport policy, Research and Economic Unit, Scottish ExecutiveEducation Department, Scotland. Available at www.scotland.gov.uk/library5/education/lrcas-00.asp.VicHealth 2002, Creative connections: promoting mental health and wellbeing throughcommunity arts participation, Victorian Health Promotion Foundation, Melbourne.Williams, D 1996, The social impact of arts programs: how the arts measure up:Australian research into social impact. Community Arts and Adult Education Centre ofNewcastle, Working paper 8, Available at www.artshaus.com.au/communityarts/papers/Commedia.htm.

Evidence-based mental health promotion resource 43Promising Projects: promoting mental health and wellbeing through communityarts participationVicHealth acknowledge that community arts projects allow people to creatively express ideas about themselves and theircommunities in ways that celebrate and reflect their experience and identity. The Community Arts Participation Schemeprovides funding to approximately 40 community arts projects each year. Activities have included:• the creation of an arts studio• dance• a circus performance• theatre (ranging from Shakespeare to puppetry)• a visual arts exhibition.Good practice examplesShimmerThis project involved the performance of a play exploring the themes of fame and local women’s desires for relationships andchildren. Rehearsals were conducted on weekends, and a director and musical director supported the project. The projectresulted in seven sell-out performances and critical acclaim from the media. The women involved felt valued and a sense ofpride, and many discovered talents in singing, acting and movement. As a result, Platform Theatre, the auspicing organisation,benefited from an enhanced reputation.High RiseI feel like I can do anything after this. (participant, Shimmer)High Rise was a puppetry and performance project based in the Carlton high rise housing estate and the onsite Carlton SouthPrimary School. The project resulted in a large scale performance using the estate grounds as the theatre and the 12-storeybuilding as a prop for projection and display. Partnerships among a range of agencies were developed. Those involved felt theproject included all children, enhanced the children’s pride in their school and produced positive behavioural changes in thechildren.A(Maze)Participants in this project were invited to participate in regular workshops with an artist. Together, they worked on theproduction of folio and exhibition pieces. Participants explored the theme of navigating the service system, using the mazeto symbolise this them. Being based at the Bentleigh Bayside Community Health Service, the project (which receivedconsiderable media coverage) brought together the arts and health. Partnerships between a range of organisations havedeveloped as a result. Some participants have continued their art work and enrolled in arts-related further education.Many also reported making major changes at a personal level and highlighted the importance of the building of friendships.The TorchThe Torch project is an extensive program of community cultural development work in regional and metropolitan Victoria.Its evaluation indicates promising outcomes in relation effective engagement strategies, the strengthening of capacitiesamong those who are most disadvantaged, and the impact on social capital indicators. Further information can be foundat www.thetorch.asn.au/current_project.html.

44 Evidence-based mental health promotion resourceSuccess factorsEvaluation has developed a list of ‘success factors’ from the projects’ experiences. These include having:• project research and planning to identify community interest and engagement• achievable project goals• an environment supportive of participants and the creative process• appropriate skills/experience in the project team.Outcomes for individualsIn general, evaluation has revealed that the projects assisted individuals to:• develop positive relationships• gain public recognition• consider identity• enhance skills• participate economically.Some individuals have used their participation in these projects as a springboard to career opportunities. The value ofparticipation and belonging was identified as an important mental health outcome.Outcomes for organisationsMany agencies involved in these projects had never previously worked together. As a result, relationships were tested at times.But the benefits of project participation are clearly articulated:• Many organisations’ involvement resulted in enhanced reputation and strong community support. The future viability ofthese organisations is thus likely to be improved.• Relationships between the health and arts sector were strengthened through the funding of these projects.• An appreciation of the link between health and arts participation has been a positive outcome.• Short term funding for community arts projects is likely to have an impact on project sustainability.Outcomes for communitiesThese projects have worked hard to connect diverse communities through the arts. The benefits are an increasedunderstanding of culture and the importance of the arts as a vehicle for improving mental health and wellbeing.The value of partnershipsAs part of the funding agreement, projects were required to demonstrate a link between agencies or individuals to enableongoing development. The strength of the partnership approach is thus evident in each of the projects. Evaluation highlightedthe importance of resourcing the partnerships. Other partnership-related problems encountered during the projects’implementation related to untested relationships, loose agreements and the recruitment of participants.

Evidence-based mental health promotion resource45Intervention – Physical activity/exerciseThere is growing evidence that a physically active lifestyle has a positive impact onmental health outcomes in adults and children (Ekelane et al. 2004; Strawbridge etal. 2002). ‘Physical exercise’ implies regular, structured, leisure-time pursuits, while‘physical activity’ arises in everyday domestic or occupational tasks (Salmon 2001).Population group/settingThese program can target all population groups, from children to older age adults.For the elderly, activity and exercise sessions can be built into day and residentialcare programs, and in appropriate community based settings. For children, adolescentsand adults, both activity and exercise settings are diverse.EffectivenessResearch into effectiveness has focused on physical exercise rather than everydayphysical activity. Until recently, little research had been conducted to determine theeffects of physical activity on mental or social wellbeing (US Department of Healthand Human Services 2002). But there is considered to be good reason to promotephysical activity in the general public both to prevent physical and mental disorders andto promote health and wellbeing (Health Education Authority 2001). Physical activityinterventions affect healthy people as well as those with co-morbidities, but prospectiveepidemiological studies are needed to determine the extent to which physical activitymay be effective for long term positive mental health.Physical activity has been perceived as likely to have a protective effect on mentalhealth, but evidence of self-concept and self-esteem benefits from increased activityin children and adolescents (3–20 years of age) is also gathering. There is goodevidence that physical activity reduces the risk of subsequent depression for olderadults (Strawbridge et al. 2002). The World Health Organisation (2005) suggested thatphysical activity promotes psychological wellbeing, reduces stress, anxiety and feelingsof depression and loneliness, and helps prevent or control risky behaviours (especiallyamong children and young people) such as tobacco, alcohol or other substance use,unhealthy diet and violence.Much of the evidence on physical exercise is self-reported as subjective wellbeing andfeelings of improved mood following exercise, happiness, feeling better about oneself,feeling better about body image, and perceived fitness and health generally (HealthEducation Authority 2001; Salmon 2001). A limitation to the research is that it hasbeen conducted in controlled environments that often assume people find exercise tobe enjoyable. For habitual exercisers, a lack of exercise is likely affect mood change(Salmon 2001). Comparability across different forms of exercise cannot be assumed(Salmon 2001).

46 Evidence-based mental health promotion resourceThe emotional benefits of exercise (as opposed to the physiological stimulus) arelikely to be due to environmental stimuli and social interaction. Emotional benefitsand feelings of wellbeing from increased social interaction are important outcomes ofexercise/activity, because solitary exercise does not improve depression. Mental healthbenefits can be measured in terms of social interaction, but the evidence for exercise asa stand-alone intervention is not straightforward and can be applied to only segmentedpopulation groups.Ekeland et al. (2004) found moderate improvements in self-esteem from exercise. Theanalysis did not provide information on the most effective settings or specific exerciseprograms. Organised sporting clubs and bodies consistently report that participation inexercise increases social cohesion, a sense of belonging and thus social inclusion, butmore rigorous evaluations need to be conducted. Confounding factors in some studiesmake it difficult to conclude whether exercise alone produced the measurable gains(Health Education Authority 2001).Implementation issues• Exercise must be appropriate and tailored to suit people’s preferences, withparticipants’ needs and characteristics understood to determine the amount andtype of physical activity needed to promote optimal mental health.• Enjoyment is necessary for both adherence and benefits (Salmon 2001).• Brisk walking is considered a good starting point for people who are looking toincrease levels of physical activity.• Exercise frequency and sustainability of exercise are more important than format andintensity in older adults, so low intensity exercise, for example, is recommended forolder adults.• Access to public spaces suitable for physical activity cannot be taken for granted.Interventions need to identify mechanisms for enhancing the access of nontraditionalservice users to mainstream recreational and leisure activities.• Programs must create welcoming and supportive environments.• Local and state governments have responsibilities to ensure place-based strategiesinclude physical activity policies (such as safety policies) and program goals andobjectives for walking paths, bicycle paths etc.• Community and school-based physical activity schemes would benefit from theinclusion of mental health promotion aims and objectives to ensure mental healthbenefits and outcomes are openly identified and measured.

Evidence-based mental health promotion resource47CommentIntersectoral cooperation between the health and recreation/leisure sectors could bestrengthened to implement, maintain and sustain physical activity and physical exerciseprograms, including walking groups. Evaluations are needed of the health sector’sappropriate role in providing physical activity and exercise programs, and of the costs andbenefits of transferring programs from the health sector to the recreation/leisure sectors.ReferencesEkeland, E, Heian, F, Hagen, KB, Abbott, J & Nordheim, L 2004, ‘Exercise to improveself-esteem in children and young people’, Cochrane Database of Systematic Reviews,2004, no. 1.Health Education Authority 2001, Making it happen: a guide to delivering mental healthpromotion, UK Department of Health, London. Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.Salmon, P 2001, ‘Effects of physical exercise on anxiety, depression, and sensitivity tostress: a unifying theory’, Clinical Psychology Review, vol. 21, no. 1, pp. 33–61.Strawbridge, W, Deleger, S, Roberts, R & Kaplan, G 2002, ‘Physical activity reduces therisk of subsequent depression for older adults’, American Journal of Epidemiology, vol.156, no. 4, pp. 328–34.Tilford, S, Delaney, F & Vogels, M 1997, Effectiveness of mental health promotioninterventions: a review, Health Education Authority, UK Department of Health, London.US Department of Health and Human Services 2002, Physical activity fundamentalto preventing disease, Office of the Assistant Secretary for Planning and Evaluation.Washington DC.World Health Organisation 2005, ‘Benefits of physical activity’ information sheet’. WHO,Geneva. Available at www.who.int/moveforhealth/advocacy/information_sheets/benefits/en/index.htmlIntervention – Media campaigns for mental health promotionMedia campaigns are a social marketing intervention at the level of communitiesor populations. They are used to promote community awareness of mental healthissues, challenge stigma and raise awareness of attitudes towards mental healthissues. Campaign messages encourage people to understand good mental health andrecognise mental health problems and when to seek help and talk about feelings andemotions. The media is a tool for advocacy and for strengthening community capacityto take action, make decisions and feel empowered. Media methods include television,radio and newspaper advertisements, printed material through various outlets (includingmail-outs), information to professionals, open days and publicity.

48 Evidence-based mental health promotion resourceGood practiceSocial marketing and media advocacy aremore effective when part of a mix withother interventions, particularly localcommunity action.Population group/settingMedia campaigns can target community settings, local populations and segmentedpopulation groups.EffectivenessSignificant positive changes in knowledge of and attitudes towards mental health(particularly reducing stigma) have been found in UK, US and Norwegian evaluations ofmedia campaigns (Jane-Llopis et al. 2005). The development of personal skills throughchanges in behavioural intentions was found in the United Kingdom (Barker 1993). Theeffectiveness of media-based campaigns for mental health promotion is increased whena campaign is complemented by a mix of focused community activities and used overtime rather than as a brief intervention.Implementation issuesThe principles for effective health promotion media campaigns apply to campaignsseeking to promote mental health:• Use media campaigns with a mix of interventions where possible.• Reaching into segmented population groups or communities requires thedevelopment of culturally competent materials and practices.• Well designed evaluations (including cost-effectiveness measures) are neededto strengthen the evidence on the use of media interventions for mental healthpromotion.CommentA small scale evaluation of the VicHealth ‘Together we do better’ campaign found mediaadvocacy can have an impact on knowledge and attitudes in relation to mental healthpromotion literacy.ReferencesBarker, C, Pistrang, N, Shapiro, DA, Davies, S & Shaw, I 1993, ‘“You in mind”: apreventive mental health television series’, British Journal of Clinical Psychology, vol. 32,pp. 281–93.Health Education Board for Scotland 1997, Mental health promotion: strategicstatement, Edinburgh. Available at www.hebs.scot.nhs.uk/info/strategy.Jane-Llopis, E, Barry, M, Hosman, C & Patel, V 2005, ‘Mental health promotion works:a review’, IUHPE – Promotion and Education, vol. 2, pp. 9–25.Tilford, S, Delaney, F & Vogels, M 1997, Effectiveness of mental health promotioninterventions: a review, Health Education Authority, UK Department of Health, London.

Evidence-based mental health promotion resource 49Addressing violence anddiscrimination 4

50 Evidence-based mental health promotion resource4 Addressing violence and discrimination4.1 Overview of violence and discriminationViolence and discrimination are determinants of mental health and wellbeing that arelinked to the need to strengthen community action, re-orient health systems and buildhealthy public policy.4.1 DiscriminationDiscrimination is defined as ‘the process by which a member, or members, of a sociallydefined group is, or are, treated differently (especially unfairly) because of his/her/theirmembership of that group...this unfair treatment arises from socially derived beliefseach group holds about the other, and patterns of dominance and oppression, viewedas expressions of a struggle for power and privilege’ (Krieger 2001 cited in VicHealth2005a, p 38. The links between discrimination and mental health are generallysegregated according to the type of discrimination (that is, gender, race, age, cultureor sexuality). Higher levels of discrimination are associated with poorer mental health(Krieger 2000 cited in Rychetnik & Todd 2004). More specifically, the link betweenracial discrimination and mental health has been well documented. Research has foundan association between racial discrimination and anxiety disorder, and other mentalhealth conditions (Rychetnik & Todd 2004).Forms of discrimination exist in all societies. Depending on the taxonomy of prevalenttypes of discrimination, race, ethnicity, sexuality and gender are all classified asfactors in discrimination, and they are all related to social exclusion because peopleor populations are often excluded on the basis of their difference. The major types ofdiscrimination are based on race and ethnicity, gender, sexual preference and disability.All discrimination types are embodied in inequalities of health (Krieger 2000).Racism in Australia is based on the dominance of white Anglo-Australians, whodiscriminate against subordinate groups, particularly Indigenous Australians, otherpeople of colour and/or different religious and linguistic groups. Racism is embeddedin the dominant culture and is manifest among Indigenous Australians in lower rates ofeducational attainment, lower incomes, higher rates of unemployment, reduced accessto goods and services, political disempowerment and below average health status.4.1.2 ViolenceViolence is not a clearly definable term and is often used interchangeably with ‘abuse’,‘battering’ and ‘physical force’. The recent World report on violence and health (WorldHealth Organisation 2002) identified several forms of violence, including youth violence,bullying, child abuse and neglect by parents and other caregivers, violence by intimatepartners (domestic violence), abuse of the elderly, sexual violence, self-directedviolence and collective violence.

Evidence-based mental health promotion resource51VicHealth (citing World Health Organisation 2002) divides violence into three broadcategories:1. self-directed violence, which includes suicidal behaviour, self-abuse andself-mutilation2. interpersonal violence, which is divided into:• family and intimate partner violence• bullying• community violence3. collective violence: ‘the instrumental use of violence by people who identifythemselves as members of a group against another group or set of individuals, inorder to achieve political, economic or social objectives’ (World Health Organisation2002, p. 6). The consequences of collective violence on mental health includedepression and anxiety, psychosomatic ailments, suicidal behaviour, intra-familialconflict and anti-social behaviour (World Health Organisation 2002).Data on the incidence and prevalence of violence are limited. Its availability dependson the type of violence. Verbal and psychological violence is unlikely to be reported,whereas physical violence is more visible and thus data are more readily available. Evenso, only about 31 per cent of victims of assault are reported. In 2002, approximately 2534 500 incidents of assault were reported in Australia. Of these victims, 51 per centreported that they had experienced more than one assault in the previous 12 months(ABS 2003). The Australian Bureau of Statistics estimated that 2.6 million women in1996 had experienced at least one incident of physical or sexual violence since the ageof 15 years (ABS 1996).Discrimination and violence are often linked and are similar in their associations withinequalities and social exclusion. Violence is frequently the vehicle through whichdiscrimination is played out – for example, homophobia can lead to gay bashing, sexismcan lead to gendered violence, and racism can lead to violence (as in the activities inthe United States of the Klu Klux Clan) and situations of genocide. Social exclusion,isolation and discrimination can thus lead to violence.The burden of disease apportioned to discrimination and violence is relatively unclearand often underestimated. National surveys have found that women are more likelyto experience violence from a partner (either previous or current) than a stranger(ABS 1996) VicHealth (2004a) estimated that intimate partner violence is responsiblefor 9 per cent of the total disease burden in women aged 15–45 years. The greatestproportion (60 per cent) of this burden is associated with mental health problems. Theresults of this study indicate that intimate partner violence is the highest modifiable riskfactor for the health of women aged 15–45 years, outstripping the effects of tobacco,drugs and alcohol (VicHealth 2004a).

52 Evidence-based mental health promotion resourceUseful resourcesThe Women’s Safety Strategy is available atwww.women.vic.gov.au/owa/owaimages.nsfImages/wssframework/$File/wssframework.pdf. Details of funded projects can be foundon the Office of Women’s Policy website:(www.women.vic.gov.au/).Victorian Government policies that supportviolence prevention include:• Crime prevention Victoria – saferstreets and homes: Victoria’s crime andprevention strategy 2002–2005 (www.justice.vic.gov.au/legalchannel/dojsite.nsf/)• the Victorian Community Council againstViolence, which provides a link betweengovernment and the community to helpprevent violence www.justice.vic.gov.au/CA2569020010922A/OrigDoc/• the Women’s Health and WellbeingStrategy of the Victorian Department ofHuman Services.ReferencesAustralian Bureau of Statistics 1996, Woman’s safety survey, cat. no. 4128.0, Canberra.Australian Bureau of Statistics 2003, Crime and safety, Australia, cat. no. 4509.0,Canberra.Krieger, N 2000, ‘Discrimination and health’, in Berkman, LF & Kawachi, I (eds),Social epidemiology. Oxford University Press, New York.Rychetnik, L & Todd, A 2004, Literature review to follow on from VicHealth’s 1999–2002mental health promotion framework: final report, Sydney Health Projects Group, Schoolof Public Health, Sydney University, Sydney.VicHealth 2004a, The health costs of violence: measuring the burden of diseasecaused by intimate partner violence, Melbourne.World Health Organisation 2002, World report on violence and health, Geneva.Available at www.who.int/violence_injury_prevention.4.2 Government policy supporting violence preventionThe nature and extent of violence against women in Australia are increasingly a matterfor public policy. The 1997 Commonwealth initiative, Partnerships against DomesticViolence, aimed to work with both governments and communities to prevent domesticviolence, and conducted projects at federal and state levels. Reports are available atwww.padv.dpmc.gov.au/projects/projects.htm.The National Crime Prevention Program was established in 1997 to identify andpromote innovative ways of reducing and preventing crime and the fear of crime(National Crime Prevention Council 2004). Its priorities include:• an early intervention, youth crime and families strategy• Indigenous and family violence• private sector (including fraud and small business crime)• property crime• public safety.In Victoria, much of the violence-related work has focused on protection and justice.The Office of Women’s Policy (2002) has released the Women’s safety strategy: a policyapproach. A coordinated approach to reducing violence against women, to addressissues associated with violence against women.

Evidence-based mental health promotion resource53ReferenceNational Crime Prevention Council 2004, The National Crime Prevention Program.Available at www.crimeprevention.gov.au/agd/WWW/ncphome.nsf/Page/National_Crime_Prevention_Program.Office of Women’s Policy 2002, Women’s safety strategy: a policy approach.A coordinated approach to reducing violence against women. Victorian Government,Melbourne.4.3 Overview of interventions to prevent violenceThe VicHealth Framework for the Promotion of Mental Health and Wellbeingidentified key themes for freedom from discrimination and violence as the valuing ofdiversity, physical security, and self-determination and control of one’s life. Consistentwith the population approach of this review, the interventions reviewed focus oninterpersonal violence rather than violence that is self-directed (suicidal behaviour,self-abuse or self-mutilation).The Rychetnik and Todd (2004) review of interventions focused on victims ofcollective trauma and violence (including refugees, asylum seekers and Indigenouspeople) revealed a limited literature base. Evaluation of interventions with thesepopulation groups appears to have been difficult, however. No systematic reviewsor evaluations were identified for interventions conducted with refugees or asylumseekers. Further research and investment in evaluation is thus required.The following list summarises the nine interventions reviewed in this section:1. Community-wide interventions p. 542. Community education campaigns p. 573. Programs developed for at-risk populations p. 584. Programs for young people p. 615. Programs for at-risk men p. 626. Legislative and sentencing reform p. 637. School-based bullying programs p. 648. Workplace bullying p. 659. Discrimination prevention p. 66Intervention categories (DHS 2003) used to prevent violence include one ormore of the following:• education and social marketing• settings and supportive environments• community action.

54 Evidence-based mental health promotion resourceIntervention – Community-wide interventionsCommunity-wide interventions have used a variety of strategies, including education,media, schools and policing, but have been less used than those interventionsdeveloped for specific population groups.Specific population group/settingCommunity-wide interventions could be at a local neighbourhood level, segmented toparticular populations such as parents or youth, or more broadly intended for wholepopulations.EffectivenessA range of strategies have been used, including public education and ‘neighbourhoodorganising’ in the United States. The evidence is equivocal about the effectivenessof public education campaigns. While a review of American studies (Kellerman etal. 1998) suggested that public education is largely untested, an Australian reviewidentified several studies with promising effects on perceptions about the acceptabilityof violence (Homel 1999). But the evidence, in terms of violence prevention, is notstrong for supervised after-school recreation, juvenile curfews and proactive policing(Kellermann et al. 1998).The Communities that Care program conducted in the United States focuses on activatingcommunities to implement community violence and aggression prevention systems(Hawkins, Catalano & Arthur 2002). Outcomes have included a 30 per cent decreasein school problems, a 45 per cent decrease in burglary, a 29 per cent decrease in drugoffences and a 27 per cent decrease in assault charges. These results have emergedthrough pre–post test research and need to be supported by other trial data. Thissupport may result where the program is being replicated in The Netherlands, the UnitedKingdom and Australia (see the case study below) (Jane-Llopis et al. 2005).Implementation issuesEvaluation of community-based interventions is complex, with methods still indevelopment. Most studies have been conducted in other countries, so theirapplicability to the Australian context may be limited.

Evidence-based mental health promotion resource55CommentCrime Prevention Victoria funded 10 place-based community building projects in2002, to encourage communities, government and business to work together toachieve agreed social, economic and environmental outcomes that were intended toaffect crime levels in those communities. The projects are due to be completed in 2005.The evaluation will inform future crime prevention initiatives for Australian contexts.ReferencesHawkins, JD, Catalano, RF & Arthur, MW 2002, ‘Promoting science-based preventionin communities’, Addictive Behaviour, vol. 27, no. 6, pp. 951–76.Homel, R 1999, Preventing violence - a review of the literature on violence and violenceprevention, Report for the Crime Prevention Division of the NSW Attorney-General’sDepartment, Sydney.Kellerman, AL, Fuqua-Whitley, DS, Rivara, FP & Mercy, J 1998, ‘Preventing youthviolence: what works?’, Annual Review of Public Health, vol. 19, pp. 271–92.Jane-Llopis, E, Barry, M, Hosman, C & Patel, V 2005, ‘Mental health promotion works:a review’, IUHPE – Promotion and Education, vol. 2, pp. 9–25.Rychetnik, L & Todd, A 2004, Literature review to follow on from VicHealth’s 1999–2002 mental health promotion framework: final report, Sydney Health Projects Group,School of Public Health, Sydney University, Sydney.

56 Evidence-based mental health promotion resourceCase study: Communities that Care (CTC)What is it?CTC is a program that aims to activate communities to implement strategies to reduce community violence and aggression(Hawkins, Catalano & Arthur 2002). Developed by Professors Hawkins and Catalano from the University of Washington, CTCwas designed to provide a framework to modify factors that undermine healthy youth development (Hawkins, & Catalano 1992cited in Toumbourou 1999). It combines substance abuse approaches with approaches that aim to address crime prevention.How does it work?Key leaders who have influence over organisational collaborations and resources in a specified community are firstlyidentified. After being provided with training about CTC, these leaders help to build community capacity for crime prevention.Community prevention boards are established, consisting of community leaders and intervention personnel who also undergorelevant training. Data are then gathered, including school surveys, local community knowledge and demographic data. Thisinformation is used to identify community needs and to prioritise areas requiring intervention. Each community preventionboard is provided with evaluated interventions from which to select those appropriate to its areas of priority. This ensures theadoption of an evidence-based approach to crime prevention. This is an important component of the program because thecommunity is mobilised to make key decisions about implementation. CTC takes a long term approach.Where has it been conducted?CTC has been implemented across several hundred communities in the United States. It is also being replicated inThe Netherlands, England, Scotland, Wales and Australia. In Australia, CTC research is being undertaken by the Centrefor Adolescent Health. Initial plans referred to the conduct of a randomised control trial of CTC across six local governmentsites. Additional information about the trial is not yet available. The evaluation plan is available at www.aic.gov.au/publications/tandi/ti122.pdf.Has it worked?Reported outcomes using pre–post test designs of 40 communities have included a 30 per cent decrease in school problems,a 45 per cent decrease in burglary, a 29 per cent decrease in drug offences and a 27 per cent decrease in assault charges(Want to read more?• Crow, I, France, A, Hacking, S & Hart, M 2004 Does Communities that Care work? An evaluation of a community-based riskprevention programme in three neighbourhoods, Joseph Rowntree Foundation, York. Available at www.jrf.org.uk/bookshop/eBooks/1859351840.pdf.• Centre for Adolescent Health, Australia (www.rch.org.au/cah/research/index.cfm?doc_id=1011).• Hawkins, JD, Catalano RF and Arthur MW 2002, Promoting science-based prevention in communities. Addictive Behaviours,Vol 27, pp 951-976.• Toumbourou, JW 1999 Implementing Communities That Care in Australia: A community mobilisation approach to crimeprevention. Trends & Issues in Crime and Criminal Justice. No. 122, July, pp1-6.• UK CTC program (www.communitiesthatcare.org.uk/index.html). Publications emerging from this program (including aguide to promising approaches) are available for purchase at www.communitiesthatcare.org.uk/publications.html.

Evidence-based mental health promotion resource57Intervention – Community education campaignsCommunity education campaigns are those implemented through media outlets.They are generally broad in scope and aim to increase knowledge and awareness.Specific population group/settingThese interventions are intended for whole of a community, with the aim of increasingawareness and educating against violence.EffectivenessThere appears to be limited evaluation of the effectiveness of community-wideeducation campaigns. No reviews of these types of intervention were identified.The Western Australian Government has funded a long term media strategy, ‘Freedomfrom Fear’, to ensure the safety of women, children and other victims of intimate partnerviolence. The strategy is based on the premise that legal threats and sanctions, whileimportant, do not remove the fear of recurring domestic violence (Donovan, Paterson& Francas 1999). Evaluation revealed improvements in men’s awareness about whereto seek assistance if they are, or could be, violent (Donovan et al. 2000; Gibbons &Paterson 2000). In addition, evaluation revealed a strong correlation between thenumber of calls to the men’s domestic violence helpline and the advertising schedule.The strength of this correlation is not provided.Implementation issuesAdequate planning to evaluate mass media interventions is required to contribute to theevidence base.ReferencesDonovan, RJ, Francas, M, Paterson, D & Zappelli, R 2000, ‘Formative research formass media based campaigns: Western Australia’s freedom from fear campaigntargeting male perpetrators of intimate partner violence’, Health Promotion Journal ofAustralia, vol. 10, no. 2, pp. 78–83.Donovan, RJ, Paterson, D & Francas, M 1999, ‘Targeting male perpetrators of intimateviolence: Western Australia’s “Freedom from Fear” campaign’, Social MarketingQuarterly, vol. 5, no. 3, pp. 128–44.Gibbons, L & Paterson, D 2000, ‘Freedom from fear campaign against domesticviolence: an innovative approach to reducing crime’, Paper presented at ReducingCriminality: Partnerships and Best Practice convened by the Australian Instituteof Criminology in association with the Western Australian Ministry of Justice, theDepartment of Local Government, the Western Australian Police Service and SaferWA, Perth, 31 July – 1 August.

58 Evidence-based mental health promotion resourceIntervention – Programs developed for at-risk populationsThe most successful interventions appear to be those developed for population groupswho are at particular risk, or have a history, of perpetrating violence against others.Empirical evidence suggests that poor parent–child relationships and marital conflictincrease the risk that children will develop major behavioural and emotional problems,including juvenile crime and anti-social behaviour (Sanders 2003; Sanders, Markie &Turner 2003).Specific population group/settingActivity has focused on two population groups: children at risk of developing violentbehaviour, and their parents. Settings have included home visitation, preschools andsocial support services. Justice-based programs are beyond the scope of this review.Effectiveness• Home visitation programs appear to be effective at preventing child abuse (HealthEducation Authority 2001; Kellermann et al. 1998). Further monitoring is needed toassess the effect on youth violence.• Family therapy has had moderate to good effects in improving family functioning andreducing behavioural problems in children (Health Education Board for Scotland2001; Kellermann et al. 1998). In Australia, the Positive Parenting program (TripleP) has been successful in improving parenting skills, reducing reported behaviouralproblems in children and improving parental wellbeing and relationship satisfaction(Sanders, Markie & Turner 2003).• Early childhood education programs have had both long term and short termeffects on reducing youth crime participation (Health Education Authority 2001;Kellermann et al. 1998). One such program, the Syracuse family developmentresearch project, combined early childhood education, parent education and linksto social services. Long term follow-up revealed only 6 per cent of participants hada juvenile record by age 15 years, compared with 22 per cent of controls. Thesuccess of the Perry Preschool program is also well documented (Anderson et al.2003). Participants were followed up to age 27 years. Significant improvements inhigh school graduation, employment status and home ownership were noted amongparticipants compared with non-participants. In addition, significant reductions inteen pregnancies, delinquency, arrests and receipt of social services were identifiedamong participants.• Behavioural and skill development programs have been identified as effectivein reducing or preventing youth violence. Individual therapy or casework is lesseffective or not effective, while cognitive behavioural therapy has had positive resultsin reducing violent crime (Health Education Board for Scotland 2001).

Evidence-based mental health promotion resource59• Sports participation has been found to be effective in reducing offending behaviour(including violence) in youth aged over 16 years who are not at school orparticipating in employment (Health Education Board for Scotland 2001).• School-based violence prevention programs intended for children who exhibitaggressive and/or violent behaviour have been effective in reducing this behaviour(Mytton et al. 2002). While individual components have not been assessed foreffectiveness, training in non-response skills and relationship skills have both beenshown to be effective.Implementation issues• Programs or interventions for preschool children appear to be more effective thanthose for older youth (15–19 years) (Kellermann et al. 1998).• Short term interventions appear to be less effective in adolescents than are thosewith a long term focus.• Much of the work has been conducted in the United States. Social circumstancesmay differ, so the generalisability of these results to the Australian context may belimited.CommentVicHealth acknowledges that interventions to address social inclusion also seek toaddress violence. This can occur through the creation of welcoming and inclusiveorganisational and community environments (VicHealth 2005b). Funded communityarts programs are also a vehicle for raising awareness of the mental health impactsof violence and discrimination. It is difficult, however, to identify the impact of theseprograms on the reduction of violence.Promising practicesParenting programs have been identified as having a promising effect on reducingviolent or aggressive behaviour in children and reducing persistent offenders’involvement in crime (Kellerman et al. 1998). A teen Triple P program conducted inQueensland showed promising outcomes for most participants (Ralph & Saunders2004). Researchers identified significant reductions in targeted risk factors (harshdiscipline, parent–teenager conflict, parental monitoring of teenager’s activities,parental depression and marital conflict). Some improvements were still beingmade after six months.

60 Evidence-based mental health promotion resourceReferencesAnderson, LM, Shinn, C, Fullilove, sMT, Scrimshaw, SC, Fielding, JE, Normand, J,Carande, VG & Task Force on Community Preventive Services 2003, ‘The effectivenessof early childhood development programs: a systematic review’, American Journal ofPreventive Medicine, vol. 24, no. 3S, pp. 32–46.Health Education Authority 2001, Making it happen: a guide to delivering mental healthpromotion, UK Department of Health, London. Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.Health Education Board for Scotland 2001, Mental health improvement: what works?,Briefing for the Scottish Executive, Edinburgh. Available at www.hebs.scot.nhs.uk/topics/.Kellerman, AL, Fuqua-Whitley, DS, Rivara, FP & Mercy, J 1998, ‘Preventing youthviolence: what works?’, Annual Review of Public Health, vol. 19, pp. 271–92.Nicholas, B & Broadstock, M 1999, ‘Effectiveness of early interventions for preventingmental illness in young people’, New Zealand Health Technology Assessment, vol. 2,No 3 , pp. 1-127 . Available at http://nzhta.chmeds.ac.nz/ymh.htm.Mytton, JA, DiGuiseppi, C, Gough, DA, Taylor, RS & Logan, S 2002, ‘School-basedviolence prevention programs: systematic review of secondary prevention trials’,Archives of Paediatric Adolescent Medicine, vol. 156, pp. 752–62.Ralph A & Saunders MR 2004 The ‘Teen Triple P’ Positive Parenting Program: apreliminary evaluation. Trends in crime and Criminal Justice No 282, Australian Instituteof Criminology, Canberra.Sanders, MR 2003. ‘Triple P Positive Parenting Program: a population approach topromoting competent parenting’, Australian e-Journal for the Advancement of MentalHealth, vol. 2, no. 3, pp. 1–17.Sanders, MR, Markie, C & Turner, KMT 2003, Theoretical scientific and clinicalfoundations of the Triple P Positive Parenting Program: a population approach to thepromotion of parenting competence, Parenting Research and Practice monograph no,1, The Parenting and Family Support Centre, University of Queensland, Brisbane.VicHealth 2005b, A plan for action 2005–2007: promoting mental health and wellbeing,Victorian Health Promotion Foundation, Melbourne.

Evidence-based mental health promotion resource61Intervention – Programs for young peopleInterventions developed for young people are often designed to break the cycle ofviolence, to raise awareness of the impacts of domestic violence, to help young peopledeal with violence, to increase community support for young people and to encouragecreativity, interaction and artistic expression.Population group/settingPrograms specifically for young people have been set in community-based organisations,including women’s health services, community health centres and welfare agencies.Programs have been offered to various population groups, ranging from wholecommunities to young people who witnessed or perpetrated domestic violence.EffectivenessA resource guide developed for the Partnerships against Domestic Violence programsuggests programs should be developed in four areas: community development, peereducation, programs provided in a school setting and community arts programs. Eacharea is supported by innovative case studies. While evaluation of intimate partnerviolence prevention interventions aimed at young people has been encouraged, fewcontrolled studies have been conducted (Strategic Partners 2000). Further, much of theevaluation has focused on knowledge and attitudes rather than changes in behaviour(Strategic Partners 2000).Implementation issuesSuccessful implementation relies on the development of cross-sectoral partnerships.Evidence of the effectiveness of these interventions is limited. Evaluation should thusbe a key component of any similar programs conducted.Promising practicesThe innovative nature of Partnerships against Domestic Violence programs and theprograms’ responsiveness to community data suggest a promising impact on theprevention of intimate partner violence.ReferencesNational Crime Prevention Council 2004, The National Crime Prevention Program.Available at www.crimeprevention.gov.au/agd/WWW/ncphome.nsf/Page/National_Crime_Prevention_Program.Strategic Partners Pty Ltd 2000, Domestic violence prevention: strategies and resourcesfor working with young people, Partnerships against Domestic Violence, Commonwealthof Australia, Canberra.

62 Evidence-based mental health promotion resourceIntervention – Programs for at-risk menPrograms that are designed to target men who are at risk of perpetrating violence.Interventions are often focused on individuals and include counselling and educationcomponents.Specific population group/settingThese interventions are generally developed for men who are at risk of becoming violenttowards their partners.EffectivenessA large scale literature review identified that counselling or education groups are mostcommonly used to prevent partner abuse by violent men (Homel 1999). Strategiesrange from cognitive–behavioural groups, couple counselling, anger re-direction,trauma therapy and programs that use a mental health and/or substance abuse focus.The reviewers identified that the literature provides only preliminary evidence on themost effective interventions. Evidence suggests, however, that an educational cognitive–behavioural approach is promising; such an approach has been effective in reducing orceasing violence.The National Crime Prevention Program has funded a number of projects, includingdomestic violence perpetrator programs and several projects focusing on the preventionof intimate partner violence in adolescents. Adolescent programs have included afocus on Indigenous adolescents. Evaluations of these programs have not identifieda quantifiable reduction in intimate partner violence – a result of the lack of tooldevelopment to measure this change (Poelina & Perdrisat 2004).Implementation issuesThe literature provides limited evidence of effective primary prevention interventions(interventions or programs that seek to prevent the occurrence of domestic violence).CommentRefer also to the discussion of community education campaigns. The Freedom fromFear campaign conducted in Western Australia focused on at-risk men.ReferencesHomel, R 1999, Preventing violence – a review of the literature on violence and violenceprevention, Report for the Crime Prevention Division of the NSW Attorney-General’sDepartment, Sydney.Poelina, A & Perdrisat, I 2004, A report of the Derby/West Kimberly project: workingwith adults to prevent domestic violence, Australian Attorney-General’s Department,Canberra.National Crime Prevention Council 2004, National Crime Prevention Program.Available at www.crimeprevention.gov.au/agd/www/ncphome.nsf/Page/National_Crime_Prevention_Program.

Evidence-based mental health promotion resource63Intervention – Legislative and sentencing reformPolicy development to prevent domestic violence has focused on tertiary-levelinterventions. These interventions tend to ensure the provision of victim centred care,with the aim of reducing further harm. They include apprehended violence orders.Specific population group/settingThese interventions target women who have been victims of some form of intimatepartner violence.Useful resourceWomen’s Health Australia is conducting theAustralian Longitudinal Study on Women’sHealth. Reports are available from thewebsite www.sph.uq.edu.au/alswh.EffectivenessA systematic review of interventions for violence against women has identifiedconflicting evidence about the effectiveness of arresting the perpetrators to reduceviolence (Wathen & MacMillan 2003). Other reviews have identified that arrest iseffective when combined with an appropriate judicial process (Holder 2001). Promisingresults have been identified from the use of civil protection orders and the provisionof legal advocacy and counselling. But more research is required before conclusivestatements about effectiveness can be made (Wathen & MacMillan 2003).Implementation issuesIt is important to note that studies reviewed by Wathen and MacMillan (2003) wereprimarily conducted in the USA. Interventions will need to be adapted for the context ofthe Australian legal system.CommentThe Australian Longitudinal Study on Women’s Health is investigating the experiencesof women who have sought legal protection. While a report suggests that legal optionscan provide effective protection, the sample size is relatively small and more follow-updata are required (Young, Byles & Dobson 2000).ReferencesHolder, R 2001, Domestic and family violence: criminal justice interventions, AustralianDomestic and Family Violence Clearinghouse issues paper 3, University of NSW, Sydney.Wathen, CN & MacMillan, HL 2003, ‘Interventions for violence against women:scientific review’, Journal of the American Medical Association, vol. 289, no. 5, pp.589–600.Young, M, Byles, J & Dobson, A 2000, ‘The effectiveness of legal protection in theprevention of domestic violence in the lives of young Australian women’, Trends andIssues in Crime and Criminal Justice, vol. 148, Australian Institute of Criminology,Canberra.

64 Evidence-based mental health promotion resourceIntervention – School-based bullying programsA range of school-based programs have been designed to prevent or reduce bullying.Specific population group/settingThese interventions target schools, classrooms, curriculum development, individualchildren and parents.EffectivenessEvidence is fairly consistent that well planned interventions can reduce bullyingbehaviour. Nonetheless, reductions in bullying have tended to be relatively smalland more commonly found in the proportion of children being victimised than in theproportion engaging in bullying (Rigby 2002).Many programs have multiple components and specific populations of interest. Onereview noted, where individual components had been compared, that curriculumcontent appeared to be effective. By comparison, the cooperative learning approachused by teachers was not shown to be effective in reducing bullying behaviour(Rychetnik & Todd 2004). School-based bullying interventions that also involve parentsand the community have been effective long term in reducing criminal behaviour,alcohol abuse, depression and suicidal behaviour (Health Education Authority 2001).Many school-based bullying prevention programs are based on the Bergen program(Rychetnik & Todd 2004; Stevens, DeBourdeadjuij & van Ooost 2001). This programwas conducted initially in Norway but has been used as a model of good practice inseveral other countries, including the United Kingdom, Canada Germany, the UnitedStates and Belgium. Strategies included in this program include the development ofschool bullying policies, curriculum work, group and individual work, playground workand peer support schemes. Program outcomes have included a 50 per cent reductionin students’ reporting bullying, a reduction in other ‘antisocial’ behaviour and animprovement in the overall ‘school climate’ (Rychetnik & Todd 2004).Implementation issues• Interventions with younger children (primary and pre-primary) are more effectivethan those conducted with older children (Rigby 2002).• Often, multiple component interventions have been implemented, and one reviewindicated that it would be difficult to identify which components, or combinations ofcomponents, are most effective (Rigby 2002).• All aspects of bullying are not always reduced in one single intervention.• Autonomy is needed at the implementation site (Rigby 2002). In particular, schoolcommitment is viewed as a possibly crucial factor in implementation success.• Interventions that involve school, parents and the community are effective and havelong term benefits (Health Education Authority 2001; Health Education Board forScotland 2001).

Evidence-based mental health promotion resource65CommentThe Gatehouse project conducted by the Centre for Adolescent Health in Australiaassists schools to increase the social connectedness of students to school and toincrease students’ skills and knowledge for dealing with everyday life challenges.Outcome evaluation commenced with the initial cohort in 1997. Follow-up surveys wereundertaken in 1999 and 2001. Evaluation findings are not yet available.ReferencesHealth Education Authority 2001, Making it happen: a guide to delivering mental healthpromotion, UK Department of Health, London. Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.Health Education Board for Scotland 2002, Mental health improvement: what works?,Briefing for the Scottish Executive. Available at www.hebs.scot.nhs.uk/topics/.Rigby, K 2002, A meta-evaluation of methods and approaches to reducing bullying inpreschools and early primary school in Australia. Report for the Australian Attorney-General’s Department, Canberra.Rychetnik, L & Todd, A 2004, Literature review to follow on from VicHealth’s 1999-2002mental health promotion framework: final report, Sydney Health Projects Group, Schoolof Public Health, Sydney University, Sydney.Stevens, V, DeBourdeadjuij, I & van Ooost, P 2001, ‘Anti-bullying interventions atschool: aspects of programme adaptation and critical issues for further programmedevelopment’, Health Promotion International, vol. 16, pp. 155–7.Intervention – Workplace bullyingThere is an emerging evidence base about the prevalence of workplace violence,particularly workplace bullying. Such bullying can include ‘offensive behaviour throughvindictive, cruel, malicious or humiliating attempts to undermine an individual orgroups of employees’ (International Labour Organisation 2005). At an individual level,workplace violence can lead to a lack of motivation, anxiety and loss of confidence(International Labour Organisation 2005). Impacts can also be felt at organisationaland community levels (International Labour Organisation 2005).Specific population group/settingInterventions can be conducted in workplaces to prevent workplace bullying.

66 Evidence-based mental health promotion resourceEffectivenessPeer reviewed journal publications have tended to focus on the incidence andprevalence of workplace violence, rather than describing preventative interventions.Much attention has been given to the importance of developing workplace bullyingprevention policies (Health Education Authority 2001; Health Education Board forScotland 2002; WorkSafe Victoria 2003). Two reviews have identified that organisationwideapproaches are most effective in dealing with workplace issues (Health EducationAuthority 2001; Health Education Board for Scotland 2002). In particular, it issuggested that interventions should include policies to tackle bullying and harassment(Health Education Authority 2001).Implementation issuesEvidence-based options for the prevention of workplace bullying should be investigatedfor effectiveness.CommentWhile interventions in Australia have included mass media campaigns and WorkCover/legislative reform, the effectiveness of these interventions in reducing workplace bullyinghas not been established.ReferencesHealth Education Authority 2001, Making it happen: a guide to delivering mental healthpromotion, UK Department of Health, London. Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.Health Education Board for Scotland 2002, Mental health improvement: what works?,Briefing for the Scottish Executive. Available at www.hebs.scot.nhs.uk/topics/.International Labour Organisation 2005, SafeWork: introduction to violence at work,Available at www.ilo.org/public/english/protection/safework/violence/intro.htm.WorkSafe Victoria 2003, Prevention of bullying and violence at work: guidance note,Available at www.workcover.vic.gov.au/vwa/publica.nsf/.Intervention – Discrimination preventionThe evidence of effective strategies to prevent discrimination is limited. Much of theevidence documents the associations between discrimination and health (includingmental health). Where interventions have been conducted, they have tended tofocus on knowledge, attitudinal and behaviour change. Rychetinik and Todd (2004)suggested that interventions designed to prevent discrimination are generally not yetovertly linked to mental health outcomes.

Evidence-based mental health promotion resource67Population group/settingPrograms have been developed for specific populations in schools and communities,particularly young people and Indigenous people.Effectiveness• Pettigrew and Tropp (2000) conducted a meta-analysis of prejudice reductionprograms based on intergroup contact. The ‘contact hypothesis’ predicted reductionsin discrimination under the following conditions: equal status between the groupsin the situation; cooperative activity towards common goals; perception of commoninterests and common humanity; and support for the contact by authorities or localnorms (Rychetnik & Todd 2004). Findings revealed that of the 203 studies included,94 per cent identified an inverse relationship between contact and prejudice(Rychetnik & Todd 2004). Pettigrew and Tropp (2000) concluded that ‘optimalintergroup contact’ should be a critical component of interventions to reduce prejudice.• A review investigating school-based interventions suggested the implementationof five types of intervention: racially integrated schooling, bilingual education,multicultural and anti-racist education, training in social–cognitive skills, and roleplaying and empathy (Aboud & Levey 2000 cited in Rychetnik & Todd 2004).• The known effectiveness of interventions in reducing prejudice towards AboriginalAustralians is limited, given a lack of formal evaluation of such programs (Hill &Augoustinos 2001). Evaluation is thought to be particularly problematic as a resultof the multi-strategic nature of the programs. A project conducted with employees ofa large public health organisation in South Australia was found to be effective in theshort term, but outcomes were not sustained. This program used Indigenous peerleaders (who also worked in the health organisation) to educate other staff membersabout Aboriginal history and culture, with the aim of reducing prejudice. Otherprograms conducted internationally have identified similar effects with some lesssignificant results.• Often, only short term outcomes have been assessed (Rychetnik & Todd 2004).Implementation issuesThere is limited empirical support that interventions have reduced discrimination.CommentEvidence links racial or ethnic discrimination with poorer physical and mental health.Research to date, however, does not adequately examine this association, so doesnot describe how exposure to discrimination can lead to increased risk of poor mentalhealth. It is crucial that this link be more clearly established (Williams, Neighbors &Jackson 2003).

68 Evidence-based mental health promotion resourceUseful resources for the preventionof violence and discriminationBullyingVarious projects such as The FriendlySchools Project, MindMatters, Peer Supportand Program Achieve (United States) areavailable at www.bullyingnoway.com.au.Domestic violenceThe Australian Domestic andFamily Violence Clearinghouse(www.austdvclearinghouse.unsw.edu.au)has a wealth of information on domesticand family violence, including resourcesand publications, a library service, a goodpractice database, research, links and news.ReferencesHill, ME & Augoustinos, M 2001, ‘Stereotype change and prejudice reduction: short andlong term evaluation of a cross-cultural awareness programme’, Journal of Communityand Applied Social Psychology, vol. 11, pp. 243–62.Pettigrew, TF & Tropp, LR 2000, ‘Does intergroup contact reduce prejudice? Recentmeta-analytical findings’, in Oskamp, S (ed), Reducing prejudice and discrimination,Lawrence Erlbaum Associates, Mahway, New Jersey.Rychetnik, L & Todd, A 2004, Literature review to follow on from VicHealth’s 1999–2002mental health promotion framework: final report, Sydney Health Projects Group, Schoolof Public Health, Sydney University, Sydney.Williams, DR, Neighbors, HW & Jackson, JS 2003, ‘Racial/ethnic discrimination andhealth: findings from community studies’, American Journal of Public Health, vol. 93,no. 2, pp. 200–208.Partnerships against Domestic Violenceis the face of Australia’s national actionprogram. Reports are available at www.padv.dpmc.gov.au/.Report from the Freedom from Fearcampaign against domestic violence areavailable at www.freedomfromfear.wa.gov.au/default.htm.General informationThe Australian Institute of Criminologywebsite (www.aic.gov.au/research/localgovt/cwlth.html#initiatives) outlines governmentresponses to violence and provides casestudies of violence prevention strategies.

Evidence-based mental health promotion resource 69Increasing access toeconomic resources 5

70 Evidence-based mental health promotion resource5 Increasing access to economic resources5.1 Overview of economic participationEconomic participation is a determinant of mental health and wellbeing, inextricablylinked to the Ottawa Charter for Health Promotion (World Health Organisation 1986)(appendix B) through the action areas of healthy public policy, supportive environmentsand the development of personal skills. The broad determinant of access to economicresources (and thus economic participation) is strongly correlated with mental healthat all life stages. While access to economic resources is frequently conceived in termsof individuals, it has important social dimensions. Paid work is a highly valued activitythat produces many more outcomes than those of financial reward, although fairfinancial reward is a highly valued outcome. Access to work, education, housing andmoney is about economic wellbeing, which is strongly connected to health status whereimprovements to people’s economic situations have significant impacts on their health(Mulvihill, Mailoux & Atkin 2001). Work, education, appropriate housing and sufficientmoney to live both protect and promote mental health and wellbeing.Economic wellbeing is a term that engages with concepts of equity, social inclusion/exclusion, socioeconomic status, inequalities, access to income and employment, andthe economic integration of marginalised groups. VicHealth evaluations have identifiedoutcomes of economic participation as including not just access to appropriate levelsof income, but also the enhancement of life skills, the promotion of attachment andbelonging, and increased opportunities for control (VicHealth 2003, p. 55).Lack of access to economic resources results in income poverty and its sequelae, ofwhich inequity is the most prominent. Income inequality is highly correlated with poorerhealth outcomes in specific diseases such as heart disease and diabetes (Garrard et al.2004) or in patterns of mental disorders (Puska & Vartiainen 1999). People at the lowerlevels of the socioeconomic hierarchy have significantly worse health status becausethe effects of economic disadvantage and persistently low income are cumulative,so sustained hardship produces a greatest risk of poor mental and physical health(Marmot & Wilkinson 2002; Puska & Vartiainen 1999).

Evidence-based mental health promotion resource71Cycles of disadvantage are complex and multidimensional, and include associations withlow levels of economic participation, which include lack of money, lack of work and lackof opportunity to acquire education and skills. Changing education, training and labourmarkets, together with fractured levels of social cohesion and restructuring of social andeconomic institutions, have created challenging circumstances for many populationgroups (VicHealth 2003). A critical dimension of economic wellbeing is access toaffordable, accessible and appropriate health services. Populations who do not haveaccess to economic resources and health services suffer significant health inequities(Freudenberg 2000). The structural arrangements governing health insurance systemsare thus a key determinant of health, because universal health insurance is regarded asa component of a social wage system. Greater equity of access has been equated withthe provision of universally funded public health insurance systems to which everyonehas equal access on the basis of need rather than ability to pay.Access to economic resources is a determinant of health related to social inclusionand connectedness. Economic participation is a key dimension of social inclusion, soit follows that labour market exclusion is a key dimension of social exclusion (JosephRowntree Foundation 2000). People policies used by community/neighbourhoodregeneration programs are often framed in terms of economic outcomes.

72 Evidence-based mental health promotion resourceCase study: the Winning New Jobs Program – promoting re-employment andmental healthThe Winning New Jobs Program was developed in the United States to help unemployed workers effectively seekre-employment and cope with the multiple challenges of unemployment and job search (Caplan et al. 1989; Price et al.1992; Price & Vinokur 1995). The program is based on theories of active learning process, social modelling, gradualexposure to acquiring skills, practice through role playing, and inoculation against setbacks.Over one week, five intensive half-day workshops are held. The workshops focus on identifying effective job search strategies,improving participants’ job search skills, increasing self-esteem and confidence, and motivating participants to persist in jobsearch activities. Two trainers deliver the program to groups of 12–20 people. The intervention is designed to achieve its goals bycreating supportive environments and relationships between trainers and participants and among participants.The program has been evaluated in replicated randomised trials involving thousands of unemployed workers and their partnersin thequality of re-employment, increased self-esteem and decreased psychological distress and depressive symptoms over two years,particularly among those with a higher risk for depression (Price et al. 1992). In addition, the program has been shown toinoculate workers against the adverse effects of subsequent job loss because workers gain an enhanced sense of masteryover the challenges of job search (Price 2003).(Source: Based on Jane-Llopis, J, Barry, M, Hosman, C & Patel, V 2005, ‘Mental health promotion works: a review’, IUHPE – Promotion and Education, vol. 2, pp. 9–25.)

Evidence-based mental health promotion resource735.2 Overview of interventions to increase access toeconomic resourcesInterventions have been developed to reduce income inequality, given links to poorerhealth outcomes among ‘those most vulnerable to poverty, and diminished lifechances’ (CCSD 2001). But interventions to address access to economic resourcesare rarely explicit in their intention to address mental health and wellbeing. TheVicHealth Framework for the Promotion of Mental Health and Wellbeing has identifiedkey themes for access to economic resources and economic participation as beingaccess to resources of work, education, housing and money.The following list summarises the four interventions reviewed in this section:1. Adult literacy programs p. 732. Child care programs p. 773. Youth employment programs p. 794. Adult work programs p. 805. Housing programs p. 83Intervention categories (DHS 2003) used to increase access to economicresources include one or more of the following:• skill development and education• settings and supportive environments• community action.Intervention – Adult literacy programsLanguage acquisition is an enabler of economic participation. Empowerment is thusan important principle of adult literacy programs. Everyone has the right to educationthat is available, accessible, acceptable and adaptable (ICESCR 1999), includingintensified adult and further education programs for those who did not acquirefunctional general literacy skills in their primary education. General literacy refers tothe degree to which individuals can read, write and compute, without regard to thecontext in which the reading and writing occur (Weiss 2005). It covers a range of skills,including reading and listening ability, numeracy, comprehension ability, the ability tocommunicate through writing and speaking, negotiation skills, critical thinking andjudgement. Literacy and numeracy are important because they promote sustainabilityof employment and underpin good health outcomes. Interventions to increase adultliteracy and numeracy programs are provided either as stand-alone programs or as partof employment programs.

74 Evidence-based mental health promotion resourceHealth literacy is one of the main forms of literacy. It is considered to include knowledgeabout health and health care; the ability to find, understand, interpret and communicatehealth information; and the ability to seek appropriate care and make critical healthdecisions, including the ability to comprehend and act on social and economicdeterminants of health. And it is believed to improve community empowerment. Other‘literacies’ include computer literacy, cultural literacy, media literacy and scientificliteracy (Rootman & Ronson 2002).There are strong links among education, employment and health. The InternationalAdult Literacy Survey (OECD & Statistics Canada 2000), a comparative study of 12Organisation for Economic Cooperation and Development countries, found a directassociation between literacy and labour market experience. People with low literacycompetency receive lower levels of income and experience unemployment for longerperiods, compared with people who have higher levels of literacy; further, they are lesslikely to secure stable and secure employment (Lamb & McKenzie 2001; Marks &Fleming 1998; Rahmani, Crosier & Pollack 2002). Illiteracy has a major negative impacton employment and health.Help with literacy skills appears to be needed among immigrant groups, with theprovision of language and literacy skills for new arrivals helping bridge social capital.Classes to assist immigrant people with language skills in the principle language of acountry are an important factor in their economic and social integration (Rahmani,Crosier & Pollack 2002).Population group/settingThese interventions target adults of all ages in a range of community-based settings,particularly those people with low general primary or secondary education, and non-English speaking new arrivals. Programs have been specifically developed for immigrantwomen, who are likely to be isolated by housework and child care responsibilities.Because men from non-English speaking backgrounds are known to be disadvantagedin employment, it follows that both men and women are population groups of interest.EffectivenessThe relationship between literacy, life opportunities, employment and mental health andwellbeing is proven to be strong (Rahmani, Crosier & Pollack 2002; Rootman & Ronson2002). Locally delivered programs, funded in the not-for-profit sector, are cost-effective(Rahmani, Crosier & Pollack 2002). While literacy programs are rarely evaluated interms of mental health promotion outcomes, participation in adult literacy programshas a positive effect on self-concept, self-esteem and self-image (Beder 1999). Thedirect and indirect effects of literacy on health suggest the importance of relationshipsbetween literacy and other determinants of health, including early childhood, ageing,personal skills and capacity, gender, age and culture (Rootman & Ronson 2002).

Evidence-based mental health promotion resource75Implementation issues• Settings must be natural to participants and integrate literacy with healthpromotion actions.• Health promotion actions should be based on Ottawa Charter principles.• Program designers must understand that ‘literacy has a colourful spectrumof meanings related to self-expression, culture, equity, empowerment andmarginalisation’ (Rootman & Ronson 2002, p. 4).• Social, economic and health service exclusion of low literate populations iscommon and serves to distinguish them as ‘hard-to-reach’ populations.• Programs to avoid are those that are labelled ‘literacy’ or that reveal otherdeficiencies among potential participants.• Integration of health into literacy programs is perceived as adding value for thedevelopment of ‘hard skills’ (reading and writing) with ‘soft skills’ (such as speaking,presenting and discussing).• Program design should be based on the learner’s needs, interests and motivations.• Learners should be involved in program design.• Participatory action research is needed to collect meaningful data.• Settings approaches in health have promising parallels for programs in literacy,and literacy and health.• Programs should be evaluated for their mental health outcomes as well otheroutcomes.CommentThe development of outcome indicators related to mental health and wellbeing islikely to increase knowledge about the effect of literacy on mental health. Measures ofliteracy need to investigate a range of literacy components, not just reading and writing(although these two components remain the cornerstone of literacy for good health andaccess to economic resources).Partnerships between the health sector and the education and training sectors willfacilitate the integration of program intentions.

76 Evidence-based mental health promotion resourceReferencesBeder, H 1999, The outcomes and impacts of adult literacy education in the UnitedStates, National Center for the Study of Adult Learning and Literacy, Harvard GraduateSchool of Education, Cambridge, Massachusetts. Available at www.gse.harvard.edu/ncsall/research/report6.pdf.ICESCR (International Committee on Economic, Social and Cultural Rights) 1999,‘The right to education’, General comment 13, para 14.Lamb, S & McKenzie, P 2001, Patterns of success and failure in the transition fromschool to work in Australia, Longitudinal Surveys of Australian Youth research report no.18, Australian Council for Educational Research Ltd, Melbourne.Marks, GN & Fleming, N 1998, Factors influencing youth unemployment in Australia1980–1994, Longitudinal Studies of Australian Youth, Australian Council of EducationalResearch, Melbourne, Available at www.acer.edu.au/research/LSAY/.Mulvihill, M, Mailloux, L & Atkin, W 2001, Advancing policy and research responses toimmigrant and refugee women’s health in Canada, Canadian Women’s Health Network,Manitoba.OECD (Organisation for Economic Cooperation and Development) & Statistics Canada2000, Literacy in the information age: final report of the International Adult LiteracySurvey, Paris.Rahmani, Z, Crosier, T & Pollack, S 2002, Evaluating the impact of the literacy andnumeracy training programme for job seekers, Australian Department of Education,Science and Training, Canberra.Rootman, I 2002, Literacy and health research workshop: setting priorities in Canada.Available at www.nlhp.cpha.ca/clhrp/wrkshp_e/wrkshpre.pdf.Rootman, I & Ronson, B 2002, The National Literacy and Health Program (Canada).Available at www.nlhp.cpha.ca/.Good practiceThe United Wood Cooperative: turning the great Aussie tool shed into amulticultural health promoting enterpriseThis innovative initiative has focused on older men from refugee backgrounds,in inner city Melbourne. The Adult Multicultural Education Service formed apartnership with the Moonee Valley Council to provide premises for an enterprisemaking boutique furniture items. A project worker supports the cooperative.Participants are involved with employment opportunities, provided with educationand training, and build partnerships (and thus awareness) with the local community.

Evidence-based mental health promotion resource77Intervention – Child care programsChild care is defined as a continuum of care of preschool children and childrenunder the age of 12 years outside regular school hours, by people who are not familymembers. High quality child care is carefully defined in the literature separately fromlow quality child care, which is more likely to occur when caregivers are untrained,caring for too many children at a time and dissatisfied with the job.Publicly funded or subsidised child care programs:• promote women’s economic and social equality by ensuring child care is affordable(thus enabling increased access to employment)• ensure families can meet workplace responsibilities, have an adequate income andbecome economically self-reliant• reduce poverty.Women carry a greater burden of familial obligation when they are required to act ascarer or mother, and they have reduced opportunities to participate in the paid workforce(or train for participation) when they have no reliable or affordable child care available.Women who have extended periods of leave from the workforce forgo direct earningsand lose life earnings and superannuation, opportunities to accumulate work experience,seniority and career advancement. Benefits of child care accrue to children, women,families, employers, communities and society through the development of a healthyeconomy based on equity principles. Child care programs should thus be informed bygender equity principles. They are also related to other health determinants, includingsocial connectedness, social inclusion and social support.The Organisation for Economic Cooperation and Development (OECD and StatisticsCanada 2004, pp. 76–7) argued that public money should be provided to only publicand non-profit child care services, with financial transparency ensured through strongparent management boards, and that a public agency should oversee the mapping ofservices and their location.Population group/settingThese interventions target workplaces, community support structures (such as thoseprovided by local, state and federal governments), families (especially mothers,particularly single and low incomes mothers) and women from immigrant families.

78 Evidence-based mental health promotion resourceUseful resourcesThe Canadian Childcare Resource andResearch Unit (CRRU) at the University ofToronto has a mandate to advance the ideaof a universal, high quality, publicly funded,not-for-profit, inclusive early childhoodeducation and care. The website (www.childcarecanada/org) has a comprehensiverange of research and commentary paperson child care issues, including data on earlychildhood care, affordability, access, publicand private provision of child care, quality,and child development.EffectivenessIn relation to economic participation, quality child care meets the needs of a rangeof population groups of interest, including children, women, families and employers(Australian Council of Trade Unions 2003; Doherty et al. 1995). Nationwide studiesshow that families with high quality child care services have reduced absenteeism ratesand their organisations have increased productivity (Cleveland & Krashinsky 2003).For single or poor mothers, the availability of child care makes the difference betweenfinancial independence and subsistence on social security benefits.Implementation issues• Strong government regulation of all aspects of child care is necessary to ensurehigh quality child care is provided.• High quality child care is enabled by adequate funding for sufficient staff withappropriate education and training, where government regulates licensing.• Publicly funded child care and that operating on a not-for-profit basis are morelikely to provide high quality, affordable, accessible child care (Doherty et al. 1995)• Equity and access to affordable, accessible services rests with the public andnot-for-profit sectors (OECD & Statistics Canada 2004).ReferencesAustralian Council of Trade Unions 2003, Child care background paper, Carlton,Available at www.actu.asn.au/congress2003/draftpolicies/.Doherty, G, Rose, R, Friendly, M, Lero, D & Hope-Irwin, S 1995, Child care: Canadacan’t work without it, Occasional paper no. 5, Childcare Resource and Research Unit,University of Toronto, Available at www.childcarecanada.org/resources/CRRU/pubs.Cleveland, G & Krashinsky, M 2003, Financing early childhood education and careservices in OECD countries, University of Toronto at Scarborough paper commissionedby the OECD for the Thematic Review of ECEC Policy, TorontoMcDonald, P 1998, Issues in child care policy in Australia, Australian NationalUniversity submission to the Senate Community Affairs Committee into Child CareFunding, Canberra.OECD (Organisation for Economic Cooperation and Development) 2004, Canada:country note – early childhood education and care policy, OECD Directorate forEducation, Paris.

Evidence-based mental health promotion resource79Intervention –Youth employment programsYouth unemployment in Australia is consistently much higher than adult unemployment.Poor school performance in literacy and numeracy is the one consistent factor in youthunemployment. Patterns of unemployment and earnings over time reveal degrees ofinequality across social groups. Low levels of employment and earnings are related tolower health status and health inequities. Job readiness programs focus on young peoplewith high levels of risk factors and low levels of protective factors.Population group/settingThese interventions target young people, especially early school leavers and thoseexperiencing disconnection or marginalisation from social and economic life.EffectivenessLongitudinal Surveys of Australian Youth (LSAY) have shown that participation in youthemployment programs that young participants consider worthwhile has positive mentalhealth and wellbeing outcomes (Marks & Fleming 1998). Participation provides socialconnectedness, skills and knowledge development, attributes such as confidence,feelings of being valued, and a sense of meaning and purpose. Completion of year 12schooling and post-school training seem to provide increased employability (Marks &Fleming 1998). Early school achievement and literacy and numeracy skills are alsocritical to overcoming unemployment, even when post-school qualifications and labourmarket experience are taken into account.Implementation issues• Education and training need to include literacy and numeracy skill building.• Building partnerships to engage with youth at all stages of the project is essential,including the planning, decision making and evaluation stages.• Interventions must work strategically to build the capacity of individuals andcommunities.• Diversity and inclusion must be included as outcomes.• Interventions should provide concrete and immediate benefits for youth, includingincome and public recognition of the value afforded their efforts.• Interventions must be conscious of establishing sustainable social and economicsecurity for youth (Jane-Llopis et al. 2005).

80 Evidence-based mental health promotion resourceCommentMoodie and Jenkins (2005) commented on the low levels of awareness amongbusiness and industry of their role in promoting mental health in the workplace. Rarelyare employment programs promoted in terms of their effect on mental health. Goodemployers are health promoting!ReferencesJane-Llopis, E, Barry, M, Hosman, C & Patel, V 2005, Mental health promotion works: areview, IUHPE – Promotion and Education, vol. 2, pp. 9–25.Marks, GN & Fleming, N 1998, Factors influencing youth unemployment in Australia1980–1994, Longitudinal Studies of Australian Youth, Australian Council of EducationalResearch, Melbourne Available at www.acer.edu.au/research/LSAY/.Moodie, R & Jenkins, R 2005, ‘I’m from the government and you want me to investin mental health promotion. Well why should I?’, IUHPE – Promotion and Education,vol. 2, pp. 27–41.VicHealth 2003, Promoting young people’s mental health and wellbeing throughparticipation in economic activities – key learnings and promising practices, VictorianHealth Promotion Foundation, Melbourne.Intervention – Adult work programsWork of different types is categorised by attributes across a continuum from ‘high grade’employment to ‘low grade’ employment. High grade employment typically has attributesthat are relatively good and a lower risk of unemployment. Low grade employment isdistinguished by relatively poor job attributes and negative material effects, includinghealth effects (Cave et al. 2001). Adult work programs are described in various terms,including ‘return to work’ or ‘welfare to work’ programs, and enhance personal job searchskills such as self-esteem and inoculation against setbacks (Jane-Llopis et al. 2005).Strategies used to increase income equity include investment in publicly funded childcare places, investments in publicly funded education (including higher education,job training, and housing and health care), an increase in minimum wages, and thedevelopment of progressive tax policies.

Evidence-based mental health promotion resource81Population group/settingAdults experiencing unemployment or underemployment for various reasons includethose with involuntary job loss and those who need to retrain and acquire neweducation and skills such as assertiveness (Health Education Authority 2001). Menfrom non-English speaking backgrounds are a priority group because they remaindisadvantaged in employment, even when all other factors are taken into account(Rahmani, Crosier & Pollack 2002). Other relevant groups include low income groupsand disadvantaged communities. Interventions settings include local employmentprograms.EffectivenessThe effectiveness of adult work programs is context dependent, but common impactsmeasured include job satisfaction, motivation, self-esteem, job seeking confidence andreduced depression (Health Education Authority 2001). The Winning Jobs Program hasbeen evaluated across the United States and Finland (the Työhön Job Search Program)with randomised control trials involving thousands of unemployed people and theirpartners. Short term results at a two-year follow-up showed improved re-employmentprospects and engagement with the labour market, and lower levels of distress (Jane-Llopis et al. 2005).Where people move from unemployment to low grade work, however, negative mentalhealth effects have been shown (Cave et al. 2001). Studies are needed of employmentstrategies that aim to improve work attributes to enhance mental health, includingsustained, long term changes to employment, especially in the jobs available to themost vulnerable groups of the population.Implementation issues• Program designers need to understand the local region/community and populationgroups of interest to effectively tailor programs.• Confidence in interview and job search skills, along with ongoing work support, isjust as important as literacy and numeracy skills.• Just moving unemployed people into ‘low grade’ work may not have positive healthimpacts (Cave et al. 2001). Income equity issues can be addressed at the local levelby working with local employment programs to ensure they are health promoting andnot health damaging.• Evaluations should measure impact and include a follow-up to assess outcomes overtime, including outcomes in terms of public policy and organisational practices.

82 Evidence-based mental health promotion resourceCommentEvaluations of adult work programs in terms of (at least) intermediate mental healthoutcomes (see the VicHealth Framework for the Promotion of Mental Health andWellbeing) would provide valuable complementary data to help build the case forhealth outcomes of employment. The appropriate role for measures to redress incomeinequality is contested, however, with public health benefits not always linked to incomeequity programs, and mental health outcomes almost never connected to equitymeasures. Income equity programs will remain a challenge for many years to come, butthe inclusion of mental health outcomes in evaluations will help to build the evidence onthe effects of income equity on health and wellbeing.The VicHealth (2004b) refugee relocation project indicates what other socialinfrastructure is necessary to safely and productively relocate refugees to rural areaswith employment vacancies.ReferencesBosma, H & Marmot, M 1997, ‘Low job control and risk of coronary heart disease inWhitehall (prospective cohort) study’, British Medical Journal, vol. 312, pp. 558–65.Cave, B, Curtis, S, Aviles, M & Coutts, A 2001, Health impact assessment forregeneration projects. Volume 11: selected evidence base, East London and the CityHealth Action Zone and Health Research Group, Queen Mary, University of London.Available at www.geog.qmul.ac.uk/health/.Friedlander, D & Burtless, G 1995, Five years after: the long-term effects of welfare-toworkprograms, Russell Sage Foundation, New York.Health Education Authority 2001, Making it happen: a guide to delivering mental healthpromotion, UK Department of Health, London. Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.Rahmani, Z, Crosier, T & Pollack, S 2002, Evaluating the impact of the literacy andnumeracy training programme for job seekers, Australian Department of Education,Science and Training, Canberra.VicHealth 2004b, Mental health promotion in new arrival communities: learnings andpromising practices, Victorian Health Promotion Foundation, Melbourne.

Evidence-based mental health promotion resource83Intervention – Housing programsAdequate housing is a prerequisite for employment (VicHealth 2005a) and a strategy,in conjunction with employment programs, to overcome worklessness, especially inareas of social housing with concentrated disadvantage (Carley 2002). The viciouscycle of poor mental health and poverty needs well targeted, structured investmentfor poverty alleviation (World Health Organisation 2003), including housing programs.These programs can take many forms: they include the refurbishment of public housingstock conducted as stand-alone programs, but housing improvements are also a keycomponent of area regeneration and neighbourhood renewal programs. Programtypes include housing repairs, energy efficiency improvements and the creation ofsafer and more secure areas for public housing tenants as part of neighbourhoodrenewal programs.Specific population groups/settingsThese interventions apply to public housing and low income communities.EffectivenessThere are strong associations between poor housing and poor health (Thomson, Petticrew& Morrison 2001), and good evidence that adequate, safe and secure housing has anindependent effect on physical and mental health and wellbeing (TIlford et al 1997).Mental health is likely to show improvements from housing interventions ahead ofphysical health effects in a dose–response relationship (Thomson, Petticrew & Douglas2003). Improvements have been found in measures of self-reported mental and physicalhealth, levels of service use, physical symptoms and the use of prescription drugs. Butresearch is lacking on the health gains and costs/benefits of investment in public housing,even though the basic human need for shelter is self-evident and associations havebeen found between mental health and general wellbeing and housing refurbishment.The health effects of housing programs are methodologically difficult to measure, andestablishing quality longitudinal studies in this area is difficult, given the multifactoredcontext, confounding factors associated with deprivation and also, perhaps, politicalfactors (Thomson, Petticrew & Morrison 2001).

84 Evidence-based mental health promotion resourceImplementation issues• Housing interventions need to be localised because they are context specific:different neighbourhoods need different approaches and packages of intervention(Carley 2002).• Prospective collaborative studies are needed between housing and health agenciesand academics.• Thomson, Morrison and Douglas (2003) identified a range of housing factorsassociated with health improvement, along with questions to ask in establishinghousing–health impact assessments. The impact of area-based initiatives requireslongitudinal studies that track both individuals and areas, and that closely linkevaluation and policy.• Housing is often a vertical program that lacks links with programs from other sectors.The formation of cross-sectoral partnerships is thus crucial for housing–healthprograms, and these partnerships should be incorporated into well designed verticaland horizontal people and place programs.• Setting up and evaluating indicators and outcome measures of social capital, socialexclusion, local democracy and local economic regeneration in housing programswill contribute to the evidence base about the relationship between housing andmental health and wellbeing.ReferencesCarley, M 2002, Community regeneration and neighbourhood renewal: a review ofthe evidence, Report to Communities Scotland, Edinburgh Research Department,Edinburgh.Macintyre, S & Ellaway, A 2000, ‘Ecological approaches: rediscovering the role ofthe physical and social environment’, in Berkman, L & Kawachi, I (eds), Socialepidemiology, Oxford University Press, New York, pp. 332–48.Task Force on Community Preventive Services 2003, ‘Recommendations to promotehealthy social environments’, American Journal of Preventive Medicine, vol. 24, no. 3S,pp. 21–4.Thomson, H, Petticrew, M & Morrison, D 2001, ‘Health effects of housing improvement:systematic review of intervention studies’, British Medical Journal , vol. 323, pp.187–90.Thomson, H, Petticrew, M & Douglas, M 2003, ‘Impact assessment of housingimprovements: incorporating evidence’, Journal of Epidemiology and CommunityHealth, vol. 57, pp. 11–16.Tilford, S, Delaney, F & Vogels, M 1997, Effectiveness of mental health promotioninterventions: a review, Health Education Authority, UK Department of Health, London.World Health Organisation 2003, Investing in mental health, Geneva.

Evidence-based mental health promotion resource 85Promising projects: Promoting young people’s mental health and wellbeing throughparticipation in economic activitiesIt’s not just having this job, but everything else that comes from it. (Jane, program participant)To implement the VicHealth Mental Health Promotion Plan 1999–2002, a number of projects were funded to encourage andpromote the participation of young people in economic activities. These projects were intended to provide young people with ‘aranenhancement of life skills, the promotion of attachment and belonging, and opportunities for control’ (VicHealth 2003, p. 55).In general, projects covered a range of activities, including:• employment placements• unpaid work• opportunities for income generation• education and training• interventions aimed at developing personal job search and small business skills, and providing information about options foreducation, training and employment.Good practice examplesKulcha Shift: the Brophy Family and Youth ServicesThis project combined economic participation with social welfare and community development approaches. It incorporatedfmanual, technical training, personal development opportunities and employment preparation supported each ‘activity centre’.Changing Lanes: Nagle College, BairnsdaleChanging Lanes was a diversion project based around a workshop specialising in basic fabrication, engineering and mechanicalrepair. It aimed to stimulate young people’s interest in economic participation and to provide genuine life skill learningopportunities. Participants undertook a training program and four-week work placement.Whitelion Juvenile Justice Employment ProjectParticipants in this program were undertaking a sentence at the Parkville Youth Residential Centre. The program usedcommunity and business partnerships to provide opportunities for employment skills training of young people in the centre.Key lessons• Promote activities that are purposeful to young people and communities.• Work in partnership with young people.• Involve young people in decision making.

86 Evidence-based mental health promotion resourceOutcomes for individualsThe evaluation revealed that the projects had successfully provided young peoplewith opportunities for economic participation. In particular, funded projects had the potential to:• enhance skills• enhance knowledge about work and work options• foster positive changes in individual attitudes to employment and• support participants to gain and maintain employment.Outcomes for organisationsBuilding organisational capacity for economic participation was the most successful outcome of the projects evaluated.The projects demonstrated potential to integrate concern for young people’s mental health and wellbeing into the corebusiness of agencies, so as to:• increase organisational capacity to assist young people• build referral networks among organisations• enhance understanding of mental health issues.Outcomes for communitiesThe impact of the projects on the communities involved was less clear or consistent. Some projects, however, reportedevidence of change in their community. As a result, the projects demonstrated potential to:• enhance understanding of mental health and wellbeing• enhance understanding of the links between economic participation and mental health• foster awareness of the strengths of young people• improve/sustain positive attitudes to the employment of young people.The value of partnershipsPartnerships were an invaluable tool in contributing to project sustainability. In doing so, they were able to:• broaden the expertise and resource base available to projects• foster intersectoral action in mental health promotion• enhance project impact by bringing together a broader range of agencies• provide a forum for resolving differences.VicHealth supported this partnership approach through its commissioning of the partnership analysis tool. This tool highlightsthe importance of planning for partnerships to maximise their potential contribution.Making the link between economic participation and mental healthParticipants symbolically viewed money as an indicator that their work was valued. Projects recognised that unless theydealt with issues of confidence, self-worth and resilience, mental health issues would remain as barriers to successfuleconomic participation.

Evidence-based mental health promotion resource87Program planning for mentalhealth promotion 6

88 Evidence-based mental health promotion resourceGood practiceMental health promotion program work willbe more sustainable and effective when itis supported by organisational policies thatacknowledge mental health as an explicitgoal, alongside the promotion of physicalhealth and wellbeing.6 Program planning for mental health promotion6.1 IntroductionSo far, this document has provided considerable information about the effectivenessof mental health promotion programs. Because mental health is a National HealthPriority and because mental health figures so prominently in population health andburden of disease studies, catchment-level and local health organisations (includinglocal government) are likely to have identified mental health as a priority area for action.To work effectively in the area of mental health promotion, where should planningbegin? In this section, we set out practical steps in decision making for the planning,implementation and evaluation of mental health promotion programs.The terms ‘project’ and ‘program’ are often used interchangeably. Here, we distinguishbetween the two. We refer to a project as a smaller and more discrete activity than aprogram, which is a set of activities or projects, usually at multi-levels and across two ormore organisations. A program may have a series of projects within it, and each projectmay need to have its own set of objectives and activities to ensure it is planned welland implemented effectively. Each project can be evaluated; alternatively, a team maydecide to evaluate only some projects within the overall program evaluation. Mentalhealth promotion is likely to need a multi-level program approach (figure 4) conductedacross two or more sectors and over time, keeping in mind that program effects maytake two years of activity to become evident.As discussed throughout this resource, program planning and evaluation processesfor mental health promotion should be have a determinants perspective to maximiseopportunities for effectiveness. This perspective involves understanding and selectingthose determinants that the program aims to influence, based on the evidence aboutthose determinants. The explicit inclusion of mental health promotion impacts andoutcomes asks that initiatives are explicitly and specifically directed towards promotinggood mental health (Health Education Board for Scotland 2001).Mental health and wellbeing and their determinants are not the territory only of healthdepartments and programs. They need to be interwoven across all sectors of society.Mental health thus needs more than a single project, agency or sector involved to makea difference. Work based on partnerships and multiple approaches has a multiplier effecttowards larger goals (Labonte 2003). This is sometimes referred to as integrated healthpromotion because it involves agencies and organisations from a wide range of sectorsand communities in a geographic catchment working in a collaborative manner, using amix of health promotion interventions and capacity building strategies to address priorityhealth and wellbeing issues (DHS 2003). Or to put it another way, integrated healthpromotion refers to ‘organisations from a range of sectors working in collaboration withlocal communities, using a mix of health promotion interventions and capacity buildingstrategies to address priority health and wellbeing issues’ (DHS 2003, p. 3).

Evidence-based mental health promotion resource89This section shows that program planning and evaluation are inextricably linked through‘program logic’. Logical program plans include a plan for evaluation; in turn, a plan forevaluation is useless without a good quality program plan to guide the measurement ofprogram effects. These principles apply to both large scale and small scale programsand evaluations.By adopting principles of program planning logic, the program is more to have apositive effect, and opportunities are created to provide evidence of that effectiveness.The field of mental health promotion evidence requires (a) thoroughness (or rigour) inprogram design and (b) evaluations that demonstrate effectiveness both in the programoutcomes for people and in the measurements that can contribute to the mental healthpromotion evidence base.Useful resourcesAustralian Department of Health andAged Care 2000b, Promotion, preventionand early intervention for mental health:a monograph, Mental Health and SpecialPrograms Branch, Canberra.Commonwealth of Australia 2003, Nationalmental health plan 2003–2008, Canberra.VicHealth 2005a, Mental health andwellbeing research summaries 1–4,Victorian Health Promotion Foundation,Melbourne.6.2 Steps in program planning for mental health promotionStep 1: Work out the program rationale and set prioritiesAt the outset, it is essential to develop evidence about the population group(s) ofinterest 1 who are experiencing disadvantaged health or social status, about theproblem(s) you want to address, and about the determinants that are your priorities foraction. Identify key areas that are affecting mental health and that should be includedin the program. This information provides a rationale for the program work. Many keydocuments summarise this information, including this resource. (The margin note liststhree additional documents that provide rationale for mental health promotion work.)Checklist 1: RationaleCheckBuild up evidence about the problem. Use local knowledge, experienceand expert data from the most recent population health data sources.Now, draw the links between the determinants and the health issues(that is, unemployment and low socioeconomic status are determinantsof chronic diseases, depression and anxiety, while discrimination, racismand sexism are determinants of depression, anxiety and stress, and maycontribute to unemployment, low education levels). Ensure issues thatthe community has identified as important have been combined withpopulation health data sources to add strength to the program.Identify those populations of interest experiencing disadvantaged healthor social status.Identify state and federal government policies about mental health.Using these policies to inform planning increases the likelihood that theprogram will garner political support and funding.1We prefer not to use the language of target groups, with its top-down connotations (not to mention military overtones). Working with populations in whom we have aninterest is preferable to taking aim at them or letting them know that they are in our sights.

90 Evidence-based mental health promotion resourceChecklist 1: Rationale continuedCheckIdentify who else is doing something about these issues. Examine thepolicy and socioenvironmental context that may affect the project. Withwhat other agencies and community members could you be working?How could a combined effort enhance work on this issue?Work out whom in the community these issues would most affect, andensure the needs of all groups have been considered. How strongis these groups’ engagement with the issues and with your agency?What are the project implications of their degree of engagement ordisengagement?Write an inventory of the resources available to the partnership(human, financial, information, technology) and from where you canobtain additional resources.Determine whether your agency would have to drop other work to beinvolved in this partnership for mental health promotion and to whatdegree the promotion effort can be incorporated into the agency’sother work.Checklist 2: Priority settingCheckIdentify state and federal government policies about mental health, anduse them to inform planning to increase the likelihood that the programwill garner political support and funding.Ensure the partnership has information about the determinants ofhealth and use a consensus process to prioritise which determinantswill be the priority for action.Gather the most recent population health data sources and drawthe links between the determinants and the health issues (that is,unemployment and low socioeconomic status are determinants ofchronic diseases, depression and anxiety, while discrimination, racismand sexism are determinants of depression, anxiety and stress) toensure issues identified as important by the community are combinedwith population health data sources to add strength to the program.Keep on asking what the partnership can influence.

Evidence-based mental health promotion resource91Step 2: Develop a basic program outlineBased on your rationale and priorities, develop a basic program outline that you cantake to potential stakeholders and partners to enlist their support. Use the VicHealthFramework for the Promotion of Mental Health and Wellbeing to develop a basicprogram outline that includes your proposals for:The Department of Human ServicesCommon Planning Framework refers to thisstage as problem definition.• population groups of interest• health promotion action areas• settings• levels at which intermediate outcomes are focused (individual, organisational,community, societal).If you develop goals and objectives at this stage, be prepared for them revised andreworked by your partners as they engage with the project and you negotiate theprogram to be developed.Step 3: Develop partnershipsThe establishment of partnerships is critical to the effectiveness of mental healthpromotion programs, so knowing how to establish, maintain and sustain wider networksof community groups, agencies and organisations, and other practitioners andcommunity folk is a necessary skill for effective mental health promotion practice.Planning processes of other agencies in your area may have identified priority issues(although they are likely to be health issues rather than determinants), so links could bemade to those agencies. It may also be useful to link with statewide programs workingon mental health promotion. The key for success is to choose where and how yourprogram will make a ‘conscious, deliberate and substantial effort to influence change’(Labonte 2003, p. 15) in one or more determinants of mental health and wellbeing.With your basic program outline, you are in a position to ‘sell’ the proposed programto potential partners, but your content and methods should remain fluid to ensureownership by all partners. The evidence tells us that a program, to effect change,must ‘unpack’ the underlying determinants of any health issue in terms of mentalhealth promotion outcomes, and you need to do this with your partners (even if youhave already worked it through). For this reason, when developing integrated healthpromotion programs, you should involve partner agencies in brainstorming potentialactivities that may be required to achieve the objectives. Sitting around the table tounpack the determinants may turn up new information that you had not thought about.

92 Evidence-based mental health promotion resourceUseful resourcesA useful chapter on partnerships is availablein Carley, M 2002, Community regenerationand neighbourhood renewal: a review of theevidence, Report to Communities Scotland,Edinburgh.VicHealth has a partnership evaluationtool available at www.vichealth.vic.gov.au/, which would be a useful addition toresources on partnerships for mental healthpromotion. Many new partnerships haveused this tool as a pre-test before theirpartnership and program development andthen as a post-test to evaluate their successand point to areas in which the partnershipcould be strengthened.To increase mental health and wellbeing at the level of communities (for example,schools, neighbourhoods, recreational environments, workplaces) and populations(for example, youth, new mothers, single parents, middle aged people out of work,people with a disability, the elderly) (Health Education Authority 1997; Labonte 2003),partnerships should aim to:• identify common goals and agree on the determinants of interest to the partnership• share intentions• work together on strategies to reach out and increase knowledge• intervene more than once• use a combination of intervention methods• pool and share resources.Checklist 3: PartnershipsCheckKnow whom you need to work with (the types of organisation and group).Identify whether you have worked with them in the past.Determine how you can best work with them (cooperation,coordination, collaboration).Find any evidence of the processes and outcomes that demonstratea maturing of the partnership.Identify any new actions that the partnership has generated.Work out whether the partnership is maturing through the planningprocess. How do you know?Working upstreamWe can gain a great deal of understanding about how to respond to the determinants ofmental health by identifying ‘levels’ that relate to the targeting of interventions. Turrell,Oldenburg and McGoffin (1999) identified three broad levels of factors affecting health:1. Downstream factors are those at the micro level, including treatment systems,disease management and investment in clinical research.2. Midstream factors are those at the intermediate level, including lifestyle, behaviouraland individual prevention programs.3. Upstream factors are those at the macro level, including government policies, globaltrade agreements and investment in population health research.

Evidence-based mental health promotion resource93A multi-level integrated program refers to a mix of interventions across two or moreof these levels, which are expanded in the Department of Human Services CommonPlanning Framework and figure 3. General principles have been established fordeveloping integrated health promotion programs:• Select and implement a mix of approaches and interventions using the CommonPlanning Framework.• Ensure a mix of upstream and downstream approaches to maximise effectiveness.• Include a mix of strategies that address the broad determinants of mental healthpromotion (a population focused approach) and that focus on identified targetgroup(s) (a high risk approach).• Select strategies that evidence based.• Link your interventions into broader priorities and health development plans for yourcommunity/area.• Identify financial and human resources required to successfully implement theinterventions.• Consider opportunities for working cooperatively with other agencies to either buildon or enhance investments already being made to achieve the program goal.Quality integrated mental health promotion involves implementing a mix of interventionsthat always include some activity at upstream levels. Sections 3–5 provide extensiveinformation about the broad range of interventions available for each risk factor for mentalhealth. The following checklist provides a guide for selecting intervention strategies.Checklist 4: Intervention selection and designCheckCheck that the proposed interventions will address specificdeterminants, as reflected in the program goal and objectives.Check that the selected mix of interventions (balancing individualfocused and population-wide interventions) has proved to be effectiveelsewhere in achieving the desired outcomes in terms of the programgoal and objectives.Set a strategy for involving community members in selectingintervention strategies and then planning, implementing and evaluatingthose interventions.Identify factors that will help or hinder people becoming involved, andstrategies to address those barriers.Identify which groups are most vulnerable and talk with them abouthow the proposed program can meet their needs.Identify how other key agencies can be involved in the process, andunderstand how your work will complement the work being undertakenby other agencies.

94 Evidence-based mental health promotion resourceCapacity building: support and resourcesFailure to give sufficient time and attention to the capacity building phase is the mostfrequent reason for an intervention’s failure to achieve or maintain health and wellbeingimprovements. Capacity building creates optimal conditions for success. It is concernedwith obtaining the resources (such as funds, materials and people) and organisationalsupport required to implement and sustain an intervention. Key actions areas forbuilding capacity include:• organisational development• partnerships• workforce development• leadership• resources.Work with partner agencies to brainstorm potential capacity building strategies forcreating the optimal conditions to achieve program sustainability and the program goal.Where there are limited resources or limited community and political support, it maybe necessary to change the program objectives to better fit the available resources.It is also useful to clarify the types of action required to secure greater communityand political support. Section 5.3 of the Integrated health promotion resource Kit(Department of Human Services 2003a) provides further information about capacitybuilding strategies.Checklist 5: Capacity buildingCheckIdentify the individual and collective skills and knowledge of the keypartners in the program and which staff need further skill development.Check that the agencies involved have the necessary resources,including time, infrastructure, personnel and community participation forthe program. Or be aware of how you can adapt different interventions,objectives and even program goals to suit the available resources.In relation to the budget, check that financial resources beentransparently allocated to the program.Clearly define the roles and responsibilities of the key partner agencies.Ensure all key partners have agreed and signed off on the integratedhealth promotion strategy or organisational plan.Ensure the involved agencies have support and leadership from seniormanagers, boards and governance committees for the delivery ofquality integrated health promotion services.

Evidence-based mental health promotion resource95Step 4: Generate a program planIn this stage, your partnership will need to affirm its priorities and develop a morestructured program plan. This plan is absolutely necessary to ensure everyone is ‘on thesame page’ about what will be done and with what intentions. Briefly, your plan needsto be based on program logic to link theory with practice through a series of steps.Program logic is an accepted approach to health promotion program planning thathelps practitioners to increase the effectiveness of their programs, and it is easier thanit sounds!The Department of Human ServicesCommon Planning Framework refers to thisstage as solution generation.Before embarking on the design of a newprogram, consider transferring or adaptinga program already implemented andevaluated elsewhere.Basically, a program plan based on the logic model needs to include severalfundamental components:• goals (or aims)• objectives• interventions/actions• an evaluation plan.Goals for mental health promotion programs are best established at two levels– goals for the partnership as well as goals for each individual agency involved in thepartnership – because the goals for each agency will differ from those shared by thepartnership. Keep in mind the need to incorporate local perspectives and priorities.The main difference between goals and objectives is their focus. Program goalsare statements about long term outcomes and should articulate what change to adeterminant(s) is the aim of the health promotion program. They are broad statementsthat relate to improving health and wellbeing status, through changes to determinants ofhealth and wellbeing, to quality of life and to inequities. Program goals are measured byoutcome evaluation. Program objectives, however, elaborate on and restate the goals inoperational terms – that is, what the program is meant to achieve immediately after itscompletion. They are measured by impact evaluation.Checklist 6: Goal and objective settingCheckIdentify the partnership’s and each agency’s overall beliefs in relation totheir responsibilities for the promotion of mental health and wellbeing.Determine whether there is a clear link between the program goals anda determinant for mental health and wellbeing.Determine whether there is a clear link between the program goals andobjectives for integrated mental health and promotion and the overallorganisational/strategic/corporate plan.Check that the objectives reflect the guiding principles for integratedhealth promotion.

96 Evidence-based mental health promotion resourceFor effectiveness, program objectivesshould be SMART:• Specific to a health determinant,population group or setting• Measurable in evaluation terms• Achievable given the resources andcapacities• Realistic (that is, sensible and practical)• Time limited, showing a set period for theintervention/program, allowing sufficienttime for planned changes to occur.Figure 3 provides a mental health promotion program planning template, to illustratehow to connect program goals, objectives and interventions/actions to evaluationprocesses. When developing the template, keep in mind the following principles tounderpin your mental health promotion program plan:• Ensure there is a shared understanding about the downstream–midstream–upstreamdeterminants of mental health in the community.• Ensure priority setting involves all key stakeholders for whom those determinants area priority.• Ensure processes are in place for the genuine engagement and participation of allkey stakeholders through all processes, from priority setting to implementation andevaluation.The fun part of planning is deciding on the interventions/actions that the partners willdevelop and put into action. Try not to rush into this part of your planning: ensureyour goals and objectives are settled and agreed before proceeding to the planning ofinterventions, and then make sure you have a mix of interventions (because a mix ismore effective than a single intervention). This is why cooperation with other agenciesis so important, because a partnership can bring complementary approaches andskills to your community. Figure 3 is a model for understanding this necessary mix ofupstream and downstream approaches to health promotion, and it overviews the rangeof approaches available to practitioners.

Evidence-based mental health promotion resource97Figure 3: Mental health promotion interventions continuumIndividual focusPopulation focusHealth educationSkill developmentCommunicationstrategiesGroup workBrief interventionsSocial marketingHealth informationBehaviour andattitude changecampaigns – localand statewide mediaCommunicationstrategiesHealth educationand empowermentCommunity actionCommunityparticipationCommunitydevelopment andengagementCommunity capacitybuildingAdvocacySettings andsupportiveenvironmentsInfrastructure andsystems changePolicyLegislationOrganisationalchangeWorkforcedevelopmentOutcome evaluationResearchSectors and settingsJustice Arts Workplace Housing Community EducationSport Health Local government Academia(Source: Based on Department of Human Services interventions continuum and the VicHealth Framework for thePromotion of Mental Health and Wellbeing.)

98 Evidence-based mental health promotion resourceUse the language of ‘intermediateoutcomes’ and ‘long term benefits’ fromthis resource and the VicHealth Frameworkfor the Promotion of Mental Health andWellbeing to guide your program andevaluation plans. This language will helpyou to describe what you are seeking toachieve and to set up the success criteriato guide your program.Step 5: Develop an evaluation planEvaluation enables us to learn about the effectiveness of activities, as well as thereasons that programs achieve or fail to achieve their objectives. Practitioner wisdomand more formal measures are combined in evaluation to develop the knowledgebase necessary for planning and implementing future activities. In addition, evaluationenables practitioners to meet accountability requirements and to more systematicallydocument, disseminate and promote effective practice.Mental health promotion or improvement programs necessarily account for a widerange of social, economic, political and environmental factors. Such complexity requiresmany types of evidence for effective evaluation. As described in this resource, theevidence base for health promotion interventions to reduce mental health problemsis dominated by relatively large intervention trials conducted by universities and otherresearch organisations. Smaller, community-based initiatives can be effective, but arerarely included in the published evaluation literature. Evaluation and documentation ofthese interventions will help to provide a more balanced evidence base for improvingefforts to reduce the incidence of mental health problems.Evaluating a health promotion program or intervention involves considering differentaspects of that program/intervention. These aspects are generally referred to as process,impact and outcome evaluation. As discussed, goals, objectives and interventions aremeasured by different types of evaluation (DHS 2003 adapted from Hawe et al. 1990),as shown in figure 4.Figure 4: Schema of program logic between program planning components andevaluation categoriesGoal/aims measured by Outcome evaluationObjectives and sub-objectives measured by Impact evaluationInterventions/strategies measured by Process evaluation

Evidence-based mental health promotion resource99• Process evaluation involves examining the implementation of the program. Whatelements worked? What elements were less successful? Who attended the program?Who was affected by the program (that is, what was the program reach? Who wasnot reached by the program?). Process evaluations are conducted early to midwaythrough program implementation.• Impact evaluation involves examining the intermediate outcomes you wish toachieve, which steers you to consider whether, and to what extent, the program orintervention has had an impact on people’s health. It assists in examining whetherthe set objectives and sub-objectives have been achieved. Impact evaluation forintermediate outcomes is conducted at the end of the program or a program stage.In a mental health promotion, one or two years may be a relatively short period forintermediate outcomes.• Outcome evaluation (that is, whether the program goal was achieved) is about longterm benefits (see the VicHealth Framework for the Promotion of Mental Healthand Wellbeing). It directs your partnership and your organisation to measure thelong term changes related to program goals. Local level programs are not expectedto invest in outcome evaluations, which are more likely to be commissioned for acluster of similar programs or for a statewide funded program.As discussed, it is important to begin planning evaluation, dissemination andsustainability strategies early in the program management cycle and not at the endof implementation, because evaluation works best when planned and then put intoaction over the life of the project. Program management of effective mental healthpromotion thus involves managing the total set of actions. Your schema will beimproved if it has congruence with the VicHealth Framework for the Promotion ofMental Health and Wellbeing to identify the levels, action areas, population groupsand intermediate outcomes.Figure 5 illustrates program planning steps alongside the steps in the Department ofHuman Services Common Planning Framework. Added to this is a worked example ofintermediate and long term outcomes, modelled on the VicHealth Framework for thePromotion of Mental Health and Wellbeing. Such a scheme can be easily adapted toillustrate the logic between a program’s steps and desired outcomes.

100 Evidence-based mental health promotion resourceFigure 5: Program planning schema1. Planning stage(could be sixmonths)2. Implementationstage (could be 18months or muchlonger)Rationale and vision settingPriority setting and problem definitionPartnership developmentGeneration of plan, including interventionsand evaluation planProgram implementationEvaluation and disseminationImplementation of a mix ofhealth promotion interventions and capacitybuilding strategies to achieve the programgoal and objectives3. Impact evaluation(for intermediateoutcomes, see3(b); for long termbenefits, see 3(c))3(a). Processevaluation (ofactivities/projectswithin the overallprogram)3(b). Intermediate outcomes (impact evaluation), including:IndividualOrganisationalCommunitySocietalProjects andprograms thatincrease:• involvement ingroup activities• access tosupportiverelationships• self-esteem andself-efficacy• access toeducation andemployment• self-determinationand control• mental healthliteracyOrganisationsthat are:• inclusive• responsive safe,supportive andsustainable• working inpartnershipsacross sectors• implementingevidence-basedapproaches totheir workPositive workingenvironmentsimprove the mentalhealth and wellbeingof staff.Environments thatare safe, supportive,sustainable andinclusiveEnhancedcommunity cohesionEnhanced civicengagementIncreased awarenessand recognition ofmental health andwellbeing issuesIntegrated, sustainedand supportive policyand programsStrong lesilativeplatformResource allocationGovernmentstructures3(c). Long term benefits (outcome evaluation), including:Individual levelOrganisational levelCommunity levelSocietalIncreased sense ofbelongingImproved physicalhealthLess stress, anxietyand depressionLess substancemisuseIntegrated,intersectoralresources andactivitiesCommunity valuingof diversity andactive disowning ofdiscriminationLess violenceand crimeImprovedproductivityReduced social andhealth inequalitiesImproved qualityof life and lifeexpectancyEnhanced skill levels

Evidence-based mental health promotion resource101Step 6: Implement the programWith all the details of your program plan in place, you are ready to start putting theplan into action. Your plan should give the both ‘the big picture’ (rationale, vision, aims)and specific directions for the program (objectives and actions). Ideally, it is sufficientlydetailed to take to a management committee for approval or to use in a fundingsubmission.Planning for task organisation presupposes that you know what major activities aregoing to happen and in what order. For this reason, the time frame is often constructedfirst: do you run the media campaign, then start some of the education sessions and,lastly, lobby for improved council policies? Or is there a better order? Or are all tasks tobe done at once? This ordering of activities (and often the tasks required to accomplishthem) requires a timeline. A two or three stage process of development is usual: aprogram establishment stage, an operational stage and the final impact (or outcome)evaluation stage. Timelines include start and end dates for all stages, activities andtasks. Working out this timeline can be a complicated business, and getting the orderright can mean the difference between success and failure, and between meeting thebudget or making a loss (particularly on large financially sensitive projects such ascommunity intervention projects).In addition to the timeline, you need a plan for the organisation of tasks. This plancovers which organisations in the partnership and which staff will do what, what rolethey will play and at what point. Implementation can be straightforward or complex, andmay require a number of different skills, depending on the approaches you are taking.So how do you match people to tasks? A couple of main roles and two broad skill setscorrespond to program implementation. The two skills sets required are:1. the skills to implement the strategies/interventions in the program plan – that is, skillsin health education and communication, group facilitation and leadership, mediaand policy development2. the skills to manage the program – that is, skill at ensuring the whole programis implemented; staff are well briefed, trained for specific competencies, andsupported; relationships with stakeholders are maintained; and evaluation isconducted effectively.The management role is most important to understand, given its strategic nature.Many resources are available to review management skills. Figure 6 provides somekey implementation questions to ask throughout the program.

102 Evidence-based mental health promotion resourceFigure 6: Key implementation questionsCommunicationProject monitoringSustaining thepartnershipManagingcontingenciesLeadership andinnovationAre you communicating well enough internally?Are you communicating well enough externally?Are you collecting enough good quality information aboutwhat is happening in the project?Are you analysing the information enough?Are decision-making structures clear and functioning well?Are you addressing and solving the emerging problems?Are you recognising and celebrating progress sufficiently?Are you looking for new opportunities and taking them?Are you monitoring resources regularly?Are you looking out for unforeseen circumstances or less thanhoped for reactions to the program?Are you providing enough appropriate (and shared) leadership?What capacity do you need to develop?Are you making similar decisions over and over again?Do you have the political antennae working?(Source: Based on DHS 2003.)Specialist implementation skillsOne person rarely, if ever, holds all the necessary skills for a mental health promotionprogram. In a smaller project, you might be left to do all the activities yourself (althoughyou will be surprised how many skills you pick up over time), but a team approachis necessary in larger projects. Specialist skills are critical for multi-level, multi-sectorprograms. How do you obtain them for your program?First, if you are taking a collaborative approach, the existence of a partnershipamong agencies increases the chance of one partner having the necessary skills andexperience required for each strategy. You thus need to need to choose your partnerswith such an eventuality in mind – for example, if you know low English literacy is anissue, then it might be wise to recruit local adult educators to your team.The second path is to develop training so the relevant staff or partners gain thenecessary skills. This is easier in some instances than in others – for example,staff might obtain newsletter production skills more readily than, say, communitydevelopment skills.

Evidence-based mental health promotion resource103The other most common way of obtaining particular specialist skills is to buy them.This may mean employing temporary staff, such as someone with outdoor educationskills to conduct an activity camp with young asthmatic teenagers. Or, it often meanscontracting another organisation to undertake the work – for example, an advertisingagency to run a media campaign.These three options bypass the need for you to have all necessary expertise, but theydo point to the need for management skills.Step 7: Write up evaluation reportsFinally, your mental health promotion work will be of wider benefit if you can write upyour practices and what you and the partnership learned from the program and itsprocesses. Remember, practitioner wisdom comes from people just like you; by sharingyour experience, you will be contributing to the growing body of knowledge about thepromotion of mental health and wellbeing.Contingency planningProgram progress may be slower thanenvisaged, the intended program impactmay be less than hoped for, unforeseencircumstances and reactions to the programmay occur, and unexpected opportunitiesmay arise. All these contingencies need tobe regularly addressed. This monitoring andreacting is sometimes called ‘contingencyplanning’, which is a key management skill.The following are three key elements to consider in your evaluation report:1. EvidenceIdentify the evidence you used to develop your program:(a) population health data that justified your intervention(b) program evidence – was it based on evaluations of other programs orpractitioner wisdom, or a combination of both?(c) evaluation evidence – did it work and at what outcome levels?2. Effectiveness(a) What key factors and conditions facilitated high quality implementation?(b) What adaptations did you make in adopting an existing program?(c) What made your program work?(d) With whom did you/your organisation work best? Under what circumstances?3. Dissemination planDissemination of your program findings is one of the most important ways of buildingthe evidence base of which interventions are most effective, for which groups and underwhich conditions. Dissemination enables the key lessons learned from the program tobe shared with other practitioners.

104 Evidence-based mental health promotion resource6.3 Useful websites with program planning andevaluation resourcesThe following resources may provide additional guidance on completing anevaluation plan:• The Quality Improvement Program Planning System (QIPPS), developed by theVictorian Community Health Association, is software that will assist subscribingorganisations to plan and evaluate health promotion programs. Furtherinformation can be found at www.qipps.com.• The Planning and Evaluation Wizard, developed by the South AustralianCommunity Health Research Unit (SACHRU), is available at www.sachru.gov.au/pew/index.htm. This resource assists the user to develop a case for projects,construct project and evaluation plans and write project reports.• The Northern Territory Government has developed a guide for planning andevaluating health promotion projects. While the guide is aimed at practitionerswho work with remote Aboriginal communities, many of its elements applyto other contexts. The guide is available at www.nt.gov.au/health/healthdev/health_promotion/bushbook/volume1/ch4.html. It discusses evaluation planningprocesses and provides tools for planning and evaluation. Information on theanalysis of quantitative and qualitative data is available at www.nt.gov.au/health/healthdev/health_promotion/bushbook/volume1/analyse.html#howto.• Step-by-step manuals for program evaluation are available at the US Center forDisease Control website (www.cdc.gov/eval/resources.htm).• The Victorian Department of Human Services Common Planning Framework andevaluation resources are available at www.health.vic.gov.au/healthpromotion/.• The Health Communications Unit of the Center for Health Promotion at theUniversity of Toronto has developed an excellent guide to evaluating healthpromotion programs. The guide includes examples and pro formas. In addition,it provides a comprehensive list of evaluation references. This guide is availableat www.thcu.ca/infoandresources/

Evidence-based mental health promotion resource 105References7

106 Evidence-based mental health promotion resource7 ReferencesAcheson, D 1998, Independent inquiry into inequalities in health. Report. The Stationary Office, Great Britain.Anderson, LM, Shinn, C, Fullilove, MT, Scrimshaw, SC, Fielding, JE, Normand, J, Carande, VG & Task Force on Community PreventiveServices 2003, ‘The effectiveness of early childhood development programs: a systematic review’, American Journal of Preventive Medicine,vol. 24, no. 3S, pp. 32–46.Australian Council of Trade Unions 2003, Child care background paper, Melbourne, Available at www.actu.asn.au/congress2003/draftpolicies/.Australian Department of Health and Aged Care 2000a, A framework for prevention of suicide and self-harm in Australia:areas for action, Canberra.Australian Department of Health and Aged Care 2000b, Promotion, prevention and early intervention for mental health: a monograph, MentalHealth and Special Programs Branch, Canberra.Australian Health Ministers (1998). Second national mental health plan. Canberra, Australian Government Publishing ServiceAIHW (Australian Institute of Health and Welfare) 2002, Australia’s health, Canberra.Barker, C, Pistrang, N, Shapiro, DA, Davies, S & Shaw, I 1993, ‘“You in mind”: a preventive mental health television series’, British Journal ofClinical Psychology, vol. 32, pp. 281–93.Barlow, J & Coren, E 2002, ‘Parent training programmes for improving maternal psychosocial health’, Cochrane Database of SystematicReviews, 2003, no. 4.Barlow, J, Coren, E & Stewart-Brown, S 2001, Systematic review of the effectiveness of parenting programmes in improving maternalpsychosocial health, Health Services Research Unit, University of Oxford, Oxford.Beder, H 1999, The outcomes and impacts of adult literacy education in the United States, National Center for the Study of Adult Learningand Literacy, Harvard University, Cambridge, Massachusetts. Available at www.gse.harvard.edu/ncsall/research/report6.pdf.Berkman, LF & Glass, T 2000, ‘Social integration, social networks, social support, and health’, in Berkman, LF & Kawachi, I (eds), Socialepidemiology, Oxford University Press, New York, pp. 137–73.Berkman, LF & Kawachi, I (eds) 2000, Social epidemiology, Oxford University Press, New York.Bosma, H & Marmot, M 1997, ‘Low job control and risk of coronary heart disease in Whitehall (prospective cohort) study’, British MedicalJournal, vol. 312, pp. 558–65.Bunker, S, Colquhoun, DM, Esler, MD, Hickie, I, Hunt, D, Jelineck, VM et al. 2003, ‘Stress and coronary heart disease, psychosocial riskfactors: National Heart Foundation of Australia: position statement update’, Medical Journal of Australia, vol. 178, no. 6, pp. 272–6.Campbell, C, Wood, R & Kelly, M 1999, ‘Social capital and health’, Health Education Authority, London. Available at www.hda-online.org.uk/downloads/pdfs/socialcapital_health.pdf.Caplan, RD, Vinokur, AD, Price, RH & Van Ryn, M 1989, Job seeking, reemployment, and mental health: a randomized field experiment incoping with job loss, Journal of Applied Psychology, 74, 5, pp 759-769.Carley, M 2002, Community regeneration and neighbourhood renewal: a review of the evidence, Report to Communities Scotland, Edinburgh.Cave, B, Curtis, S, Aviles, M & Coutts, A 2001, Health impact assessment for regeneration projects. Volume 11: selected evidence base, EastLondon and the City Health Action Zone and Health Research Group, Queen Mary, University of London. Available at www.geog.qmul.ac.uk/health/guide.html.

Evidence-based mental health promotion resource107Cleveland, G & Krashinsky, M 2003, Financing early childhood education and care services in OECD countries, University of Torontoat Scarborough paper commissioned by the Organisation for Economic Cooperation and Development for the Thematic Review of ECECPolicy, Toronto.Commonwealth Department of Health and Ageing, 2000, National Mental Health Report 2000: Sixth Annual Report: Changes in Australia’sMental Health Services under the First National Mental Health Plan of the National Mental Health Strategy 1993–98, Canberra: Mental Healthand Special Programs Branch, Department of Health and Ageing.Commonwealth of Australia 2003, National mental health plan 2003–2008, Canberra, Mental Health and Special Programs Branch,Department of Health and Ageing.CommunityLIFE 2004, ‘About CommunityLIFE’, website of resources available at www.community-life.org.au/about.php (accessed25 March 2004).Crow, I, France, A, Hacking, S & Hart, M 2004, Does Communities that Care work? An evaluation of a community-based risk preventionprogramme in three neighbourhoods, Joseph Rowntree Foundation, UK. Available at www.jrf.org.uk/bookshop/eBooks/1859351840.pdf.DHS (Department of Human Services) 2003, Integrated health promotion resource kit, Melbourne.Doherty, G, Rose, R, Friendly, M, Lero, D & Hope-Irwin, S 1995, Child care: Canada can’t work without it, Occasional paper no. 5, ChildcareResource and Research Unit, available at www.childcarecanada.org/resources/CRRU/pubs.Donovan, RJ, Francas, M, Paterson, D & Zappelli, R 2000, ‘Formative research for mass media based campaigns: Western Australia’s freedomfrom fear campaign targeting male perpetrators of intimate partner violence’, Health Promotion Journal of Australia, vol. 10, no. 2, pp. 78–83.Donovan, RJ, Paterson, D & Francas, M 1999, ‘Targeting male perpetrators of intimate violence: Western Australia’s “Freedom from Fear”campaign’, Social Marketing Quarterly, vol. 5, no. 3, pp. 128–44.Duggan, M & Cooper, A (nd), Modernising the social model in mental health: a discussion paper, TOPSS, London. Available at www.critpsynet.freeuk.com/duggan.htm.Eagar, K, Brewer, C, Collins, J et al. 2005, Strategies for gain – the evidence on strategies to improve the health and wellbeing of Victorianchildren, Centre for Health Service Development, University of Wollongong, New South Wales.Ekeland, E, Heian, F, Hagen, KB, Abbott, J & Nordheim, L 2004, Exercise to improve self-esteem in children and young people, CochraneDatabase of Systematic Reviews, 2004, no. 1.Frankish, J, Kwan, B & Flores, J 2002, Assessing the health of communities: indicator projects and their impacts, Institute of Health PromotionResearch, University of British Columbia, Canada. Available at http://ihpr.ubc.ca.Freudenberg, N 2000, ‘Health promotion in the city: a review of current practice and future prospects in the United States’, Annual Review ofPublic Health 2000, vol. 21, pp. 473–503.Friedlander, D & Burtless, G 1995, Five years after: the long-term effects of welfare-to-work programs, Russell Sage Foundation, New York.Fullager, S & Gattuso, S 2002, ‘Rethinking gender, risk and depression in Australian mental health policy’, Australian e-Journal for theAdvancement of Mental Health, vol. 1, no. 3, pp. 2–13.Garrard, J, Lewis, B, Keleher, H, Tunny, N, Burke, L, Harper, S & Round, R 2004, Planning for healthy communities: reducing the riskof carviovascular disease and type 2 diabetes through healthier environments and lifestyles, Victorian Department of Human Services,Melbourne.Gibbons, L & Paterson, D 2000, ‘Freedom from fear campaign against domestic violence: an innovative approach to reducing crime’, Paperpresented at Reducing Criminality: Partnerships and Best Practice convened by the Australian Institute of Criminology in association with theWestern Australian Ministry of Justice, the Department of Local Government, the Western Australian Police Service and Safer WA, Perth, 31July – 1 August.Glass, T 2000, ‘Psychosocial interventions’, in Berkman, LF & Kawachi, I 2000, Social epidemiology, Oxford University Press, New York,pp. 137–73.

108 Evidence-based mental health promotion resourceGould, MS, Greenberg, T, Velting, D & Shaffer, D 2003, ‘Youth suicide risk and preventive interventions: a review of the past 10 years’, Journalof the Academy of Child and Adolescent Psychiatry, vol. 42, no. 4, pp. 386–405.Hawkins, JD, Catalano, RF & Arthur, MW 2002, ‘Promoting science-based prevention in communities’, Addictive Behaviour, vol. 27, no. 6,pp. 951–76.Health Education Authority 2001, Making it happen: a guide to delivering mental health promotion, UK Department of Health, London,Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.Health Education Board for Scotland 2001, Mental health improvement: what works?, Briefing for the Scottish Executive, Edinburgh. Availableat www.hebs.scot.nhs.uk/topics/top.Hill, ME & Augoustinos, M 2001, ‘Stereotype change and prejudice reduction: short and long term evaluation of a cross-cultural awarenessprogramme’, Journal of Community and Applied Social Psychology, vol. 11, pp. 243–62.Hodnett, ED & Roberts, I 2004, ‘Home-based social support for socially disadvantaged mothers’, Cochrane Database of Systematic Reviews,2004, no. 4.Holder, R 2001, Domestic and family violence: criminal justice interventions, Australian Domestic and Family Violence Clearinghouse issuespaper 3, University of NSW, Sydney.Homel, R 1999, Preventing violence – a review of the literature on violence and violence prevention, Report for the Crime Prevention Divisionof the NSW Attorney-General’s Department, Sydney.ICESCR (International Committee on Economic, Social and Cultural Rights) 1999, ‘The right to education’, General comment 13, Geneva.Available online http://www.unhchr.ch/html/menu6/2/fs16.htmInternational Labour Organisation 2005, SafeWork: introduction to violence at work, Available at www.ilo.org/public/english/protection/safework/violence/intro.htm.Jane-Llopis, E, Barry, M, Hosman, C & Patel, V 2005, ‘Mental health promotion works: a review’, IUHPE – Promotion and Education,vol. 2, pp. 9–25.Jane-Llopis, E, Mittelmark, M 2005, Editorial: No health with mental health, IUHPE – Promotion and Education, vol. 2, pp. 4-5.Jermyn, H 2001, The arts and social exclusion: a review prepared for the Arts Council of England, Available at www.artscouncil.org.uk/documents/publications/298.doc.Johnson, D, Headey, B & Jensen, B 2003, Communities, social capital and public policy: literature review, Melbourne Institute working paperno. 26/03, University of Melbourne, Melbourne.Joseph Rowntree Foundation 2000, Poverty and social exclusion in Britain, UK. Available at www.jrf.org.uk/knowledge/findings/socialpolicy/930.asp.Kawachi, I & Berkman, LF 2001, ‘Social ties and mental health’, Journal of Urban Health, vol. 78, no. 3, pp. 458–67.Kawachi, I, Subramanian, SV, & Almeida-Filho, K 2002, A glossary for health inequalities. Journal of Epidemiology and Community Health, 56,pp 647-652.Keleher, H & Murphy, B 2004, (eds), Understanding health: a determinants approach, Melbourne, Oxford University Press.Kellerman, AL, Fuqua-Whitley, DS, Rivara, FP & Mercy, J 1998, ‘Preventing youth violence: what works?’, Annual Review of Public Health, vol.19, pp. 271–92.Krieger, N 2000, ‘Discrimination and health’, in Berkman, LF & Kawachi, I (eds), Social epidemiology, Oxford University Press, New York.Labonte R 2003, How our programs affect population health determinants: a workbook for better planning and accountability, Health Canada,Ottawa.Lamb, S & McKenzie, P 2001, Patterns of success and failure in the transition from school to work in Australia, Longitudinal Surveys ofAustralian Youth research report no. 18, Australian Council for Educational Research Ltd, Melbourne. Available at www.acer.edu.au/research/projects/lsay/reports/lsay18.pdf.

Evidence-based mental health promotion resource109LaMontagne, AD, Louie, A, Keegal, T, Ostry, A, Shaw, A 2005, Workplace stress in Victoria: developing a systems approach, Report to theVictorian Health Promotion Foundation, Melbourne.Lister-Sharp, D, Chapman, S, Stewart-Brown, S & Sowden, A 1999, ‘Health promoting schools and health promotion in schools: two systematicreviews’, Health Technology Assessment, vol. 3, p. 22.Macintyre, S & Ellaway, A 2000, ‘Ecological approaches: rediscovering the role of the physical and social environment’, in Berkman,L & Kawachi, I (eds), Social epidemiology, Oxford University Press, New York, pp. 332–48.Marmot, M & Wilkinson, R 2002, Social determinants of health: the solid facts, 2nd edn, World Health Organization, Geneva. Available atwww.who.dk/healthy-cities.Marks, GN & Fleming, N 1998, Factors influencing youth unemployment in Australia 1980–1994, Longitudinal Studies of Australian Youth,Australian Council of Educational Research, Melbourne. Available at www.acer.edu.au/research/LSAY/.McDonald, & O’Hara 1998, cited in Health Education Authority 2001, Making it happen: a guide to delivering mental health promotion,UK Department of Health, London, Available at www.nelf.nhs.uk/nsf/mentalhealth/makeithappen/ch3/3_0.htm.McDonald, P 1998, Issues in child care policy in Australia, Australian National University submission to the Senate Community AffairsCommittee into Child Care Funding, Canberra.McQueen, D 2001, ‘Strengthening the evidence base for health promotion’, Health Promotion International, vol. 16, no. 3, pp. 261–8.McQueen-Thomson, D & Ziguras, C 2002, Review of the health benefits of community arts practice, The Globalism Institute, School ofInternational and Community Studies, RMIT University, Melbourne.Mittelmark, MB 2003, ‘Five strategies for workforce development for mental health promotion’, IUHPE – Promotion and Education,vol. 1, pp. 20–2.Moodie, R & Jenkins, R 2005, ‘I’m from the government and you want me to invest in mental health promotion. Well why should I?’,IUHPE – Promotion and Education, vol. 2, pp. 27–41.Mulvihill, M, Mailloux, L & Atkin, W 2001, Advancing policy and research responses to immigrant and refugee women’s health in Canada,Canadian Women’s Health Network, Manitoba.Mytton, JA, DiGuiseppi, C, Gough, DA, Taylor, RS & Logan, S 2002, ‘School-based violence prevention programs: systematic review ofsecondary prevention trials’, Archives of Paediatric Adolescent Medicine, vol. 156, pp. 752–62.National Crime Prevention Council 2004, The National Crime Prevention Program, Canberra, Available at www.crimeprevention.gov.au/agd/WWW/ncphome.nsf/Page/National_Crime_Prevention_Program.National Health and Medical Research Council 1998, Guidelines for the development, implementation and evaluation of clinical practiceguidelines, Canberra.Nicholas, B & Broadstock, M 1999, ‘Effectiveness of early interventions for preventing mental illness in young people’, New Zealand HealthTechnology Assessment, vol. 2, No 3 , pp. 1-127 . Available at http://nzhta.chmeds.ac.nz/ymh.htm.Nutley, S, Walter, I & Davies, H 2002, From knowing to doing: a framework for understanding the evidence-into-practice agenda, ResearchUnit for Research Utilisation, University of St Andrews, St Andrews, Scotland.OECD (Organisation for Economic Cooperation and Development) 2004, Canada: country note – early childhood education and care policy,OECD Directorate for Education, Paris.OECD (Organisation for Economic Cooperation and Development) & Statistics Canada 2000, Literacy in the information age: final report of theInternational Adult Literacy Survey, Paris.Office of Women’s Policy 2002, Women’s safety strategy: a policy approach. A coordinated approach to reducing violence against women.Victorian Government, Melbourne.Petticrew, M & Roberts, H 2003, ‘Evidence, hierarchies, and typologies: horses for courses’, Journal of Epidemiology and Community Health,vol. 57, pp. 527–9.

110 Evidence-based mental health promotion resourcePettigrew, TF & Tropp, LR 2000, ‘Does intergroup contact reduce prejudice? Recent meta-analytical findings’, in Oskamp, S (ed.), Reducingprejudice and discrimination, Lawrence Erlbaum Associates, Mahway, New Jersey.Ploeg, J, Ciliska, D, Brunton, G, MacDonnell, J & O’Brien, MA 1999, The effectiveness of school-based curriculum suicide preventionprograms for adolescents, Ontario.Poelina, A & Perdrisat, I 2004, A report of the Derby/West Kimberly project: working with adults to prevent domestic violence, AustralianAttorney-General’s Department, Canberra.Price, R, Van Ryn, M & Vinokur, A 1992, Impact of a preventive job search interventionon the likelihood of depression among the unemployed,Journal of Health and Social Behaviour, 33, pp 158-167.Price, RH & Vinokur, AD 1995, Supporting career transitions in a time of organizational downsizing: The Michigan JOBS Program. In M.London (ed), Employees, careers, and job creation: developing growth-oriented human resource strategies and programs,San Francisco, CA, Jossey-Bass, pp 191-209.Price, RH 2003, Understanding and improving the mental health of populations, In House, JS, Kahn, RL, Juster, FT, Schuman, H & Singer, E,(eds), Telescope on society: survey research and social science at the University of Michigan and beyond. Ann Arbor, Michigan, The Universityof Michigan Press.Puska, P & Vartiainen, E 1999, Health Challenges 1: health disease, the lifestyle killer. The Evidence of health promotion effectiveness:shaping public health in a new Europe, Part Two, Evidence Book. A Report for the European Commission by the International Union for HealthPromotion and Education. Luxembourg, pp 55-68Putnam, R 2001, ‘Social Capital; measurement and consequences’, Canadian Journal of Policy Research, vol. 1, no. 2, pp. 41-51.Rahmani, Z, Crosier, T & Pollack, S 2002, Evaluating the impact of the Literacy and Numeracy training programme for job seekers, AustralianDepartment of Education, Science and Training, Canberra.Ralph A & Saunders MR 2004 The ‘Teen Triple P’ Positive Parenting Program: a preliminary evaluation. Trends in crime and Criminal JusticeNo 282, Australian Institute of Criminology, Canberra.Reidpath, D 2004, ‘Social determinants of health’, in Keleher, H & Murphy, B (eds), Understanding health: a determinants approach, OxfordUniversity Press, Melbourne.Rigby, K 2002, A meta-evaluation of methods and approaches to reducing bullying in pre-schools and early primary school in Australia, Reportfor the Australian Attorney-General’s Department, Canberra.Rootman, I 2002, Literacy and health research workshop: setting priorities in Canada. Available at www.nlhp.cpha.ca/clhrp/wrkshp_ewrkshpre.pdf.Rootman, I & Ronson, B 2002, The National Literacy and Health Program (Canada). Available at www.nlhp.cpha.ca/.Rychetnik, L & Todd, A 2004, Literature review to follow on from VicHealth’s 1999-2002 mental health promotion framework: final report,Sydney Health Projects Group, School of Public Health, Sydney University, Sydney.Salmon, P 2001, ‘Effects of physical exercise on anxiety, depression, and sensitivity to stress: a unifying theory’, Clinical Psychology Review,vol. 21, no.1. pp. 33–61.Salvaris, M, Burke, T, Pidgeon, J & Kelman, S 2000, Social benchmarks and indicators for Victoria. Consultants report for the VictorianDepartment of Premier and Cabinet by the Institute for Social Research, Swinburne University of Technology, Melbourne.Sanders, MR 2003. ‘Triple P Positive Parenting Program: a population approach to promoting competent parenting’, Australian e-Journal forthe Advancement of Mental Health, vol. 2, no. 3, pp. 1–17.Sanders, MR, Markie, C & Turner, KMT 2003, Theoretical scientific and clinical foundations of the Triple P Positive Parenting Program: apopulation approach to the promotion of parenting competence, Parenting Research and Practice monograph no, 1, The Parenting andFamily Support Centre, University of Queensland, Brisbane.Scottish Executive Education Department 2004, A literature review of the evidence base for culture, the arts and sport policy, Research andEconomic Unit, Scottish Executive Education Department, Scotland. Available at www.scotland.gov.uk/library5/education/lrcas-00.asp.

Evidence-based mental health promotion resource111Sen, A 1999, Development as freedom, Oxford University Press New York, pp. 87–110.Steering Committee for the Evaluation of the Second National Mental Health Plan 1998–2003 2003, Evaluation of the second national mentalhealth plan, Prepared for the Australian Health Ministers’ Advisory Council, Commonwealth of Australia, Canberra.Stevens, V, DeBourdeadjuij, I & van Ooost, P 2001, ‘Anti-bullying interventions at school: aspects of programme adaption and critical issuesfor further programme development’, Health Promotion International, vol. 16, pp. 155–7.Stone, W 2001, Measuring social capacity: towards a theoretically informed measurement framework for researching social capital in familyand community life, Research paper no. 24, Australian Institute of Family Studies, Melbourne.Strategic Partners Pty Ltd 2000, Domestic violence prevention: strategies and resources for working with young people, Partnerships againstDomestic Violence, Commonwealth of Australia, Canberra.Strawbridge, W, Deleger, S, Roberts, R & Kaplan, G 2002, ‘Physical activity reduces the risk of subsequent depression for older adults’,American Journal of Epidemiology, vol. 156, no. 4, pp. 328–34.Taft, A. (2003) Promoting Women’s Mental Health: The Challenges of Intimate/Domestic Violence Against Women, Issues Paper No. 8,Australian Domestic and Family Violence Clearinghouse, Sydney, University of NSW.Task Force on Community Preventive Services 2003, ‘Recommendations to promote healthy social environments’, American Journal ofPreventive Medicine, vol. 24, no. 3S, pp. 21–4.Taub, A 2001, ‘Reviewing evidence on the effectiveness of health education: methodological considerations’, Paper presented at the SecondInternational Symposium on the Effectiveness of Health Promotion, Toronto, Canada, May.Thomson, H, Petticrew, M & Douglas, M 2003, ‘Impact assessment of housing improvements: incorporating evidence’, Journal ofEpidemiology and Community, vol. 57, pp. 11-16.Thomson, H, Petticrew, M & Morrison, D 2001, ‘Health effects of housing improvement: systematic review of intervention studies’, BritishMedical Journal, vol. 323, pp. 187–90.Tilford, S, Delaney, F & Vogels, M 1997, Effectiveness of mental health promotion interventions: a review, Health Education Authority,UK Department of Health, London.Tones, K 1997, ‘Beyond the randomized controlled trial: a case for a judicial review’, Health Education Research, vol. 12, pp. 1–4.Toumbourou, JW 1999 ‘Implementing Communities That Care in Australia: A community mobilisation approach to crime prevention’,Trends & Issues in Crime and Criminal Justice. No. 122, July, pp1-6.Turrell, G, Oldernburg, B, McGuffog, I & Dent, R 1999, Socioeconomic determinants of health: towards a national research program and apolicy and intervention agenda, Brisbane, School of Public Health, Queensland University of Technology.US Department of Health and Human Services 2002, Physical activity fundamental to preventing disease, Office of the Assistant Secretaryfor Planning and Evaluation. Washington DC.VicHealth 1999, Mental health promotion plan 1999–2002, Victorian Health Promotion Foundation, Carlton South.VicHealth 2002, Creative connections: promoting mental health and wellbeing through community arts participation, Victorian HealthPromotion Foundation, Carlton South.VicHealth 2003, Promoting young people’s mental health and wellbeing through participation in economic activities – key learnings andpromising practices, Victorian Health Promotion Foundation, Carlton South.VicHealth 2004a, The health costs of violence: measuring the burden of disease caused by intimate partner violence, Victorian HealthPromotion Foundation, Carlton South.VicHealth 2004b, Mental health promotion in new arrival communities: learnings and promising practices, Victorian Health PromotionFoundation, Carlton South.VicHealth 2005a, Mental health and wellbeing research summaries 1–4, Victorian Health Promotion Foundation, Carlton South.

112 Evidence-based mental health promotion resourceVicHealth 2005b, A plan for action 2005–2007: promoting mental health and wellbeing, Victorian Health Promotion Foundation,Carlton South.Vinokur, A, Van Ryn, M, Gramlich, E & Price, R 1991, long-term follow-up and benefit-cost analysis of the Jobs Program:a preventive intervention for the unemployed, Journal of Applied Psychology, 76 (2), pp 213-219.Vinson, T. (1999). Unequal in Life. Ignatius Centre, Jesuit Social Services, Melbourne Available at www.jss.org.au.Volunteering Australia 2001, Home page at http://volunteersearch.gov.au/.Young, M, Byles, J & Dobson, A 2000, ‘The effectiveness of legal protection in the prevention of domestic violence in the lives of youngAustralian women’, Trends and Issues in Crime and Criminal Justice, no. 148, Australian Institute of Criminology, Canberra.Walker, L, Verins, I, Moodie, R & Webster, K 2005, Responding to the social and economic determinants of mental health: a conceptualframework for action, In Herrman, H, Saxena, S & Moodie, R (eds). Promoting Mental Health Concepts, Emerging Evidence, Practice:a report of the World Health Organisation, Geneva, World Health Organisation.Waring, T & Hazell, T 2002, Evaluation of MindMatters: third interim report, Hunter Institute of Mental Health, New South Wales.Wathen, CN & MacMillan, HL 2003, ‘Interventions for violence against women: scientific review’, Journal of the American Medical Association,vol. 289, no. 5, pp. 589–600.Weiss, B 2005, Epidemiology of low health literacy, In Schwartzberg, JG, VanGeest, JB & Wang, CC, Understanding health literacy:implications for medicine and public health, American Medical Association, AMA Press.Wheeler, J, Gorey, K & Greenblatt, B 1998, ‘The beneficial effects of volunteering for older volunteers and the people they serve: a metaanalysis’,International Journal of Ageing and Human Development, vol. 47, no. 1, pp. 69–79.Williams, DR, Neighbors, HW & Jackson, JS 2003, ‘Racial/ethnic discrimination and health: findings from community studies’, AmericanJournal of Public Health, vol. 93, no. 2, pp. 300–308.Williams, D 1996, The social impact of arts programs: how the arts measure up: Australian research into social impact. Community Arts andAdult Education Centre of Newcastle, Working paper 8, Available at www.artshaus.com.au/communityarts/papers/Commedia.htm.Woolcock, M 2001, ‘The place of social capital in understanding social and economic outcomes’, Canadian Journal of Policy Research, vol. 2,no 2, pp. 11-17.WorkSafe Victoria 2003, Prevention of bullying and violence at work: guidance note, Melbourne. Available at www.workcover.vic.gov.au/vwa/publica.nsf/.World Health Organisation 1986, Ottawa Charter for health promotion. World Health Organisation, Geneva.World Health Organisation 1998, Health promotion glossary of the World Health Organisation, Geneva. Available at www.who.int/hpr/backgroundhp/glossary/glossary.pdf.World Health Organisation 2001, World health report: mental health: new understanding, new hope, Geneva.World Health Organisation 2002, World report on violence and health, Geneva. Available at www.who.int/violence_injury_prevention.World Health Organisation 2003, Investing in mental health, GenevaWorld Health Organisation 2005, ‘Benefits of physical activity’ information sheet, Geneva, Available at www.who.int/moveforhealth/advocacy/information_sheets/benefits/en/index.html (accessed 31 March 2005).Wyn, J, Cahill, H, Holdsworth, R, Rowling, L & Carson, S 2000, ‘MindMatters, a whole-school approach promoting mental health andwellbeing’, Australian and New Zealand Journal of Psychiatry, vol. 34, pp. 594–601.

Evidence-based mental health promotion resource113Appendices

114 Evidence-based mental health promotion resourceAppendix A: Review methodsIntroductionThe preparation and publication of research and development reviews is commonlyundertaken to develop knowledge and improve practice. Systematic reviews are reviewsthat are conducted with particular approaches that seek to minimise bias and error inthe synthesis of a body of literature to draw conclusions and make recommendations.They are characterised by methods of systematic appraisal and summary accordingto an explicit and reproducible method, and may have narrow or broad criteria forthe inclusion of interventions. Study designs may be based on decisions that quasiexperimentalstudies are the minimum acceptable standard of evidence but, asdiscussed in this section, such studies may not be available in the field of healthpromotion or may not be ethically or technically feasible.The reviews of evidence here are informed by systematic review methods, but our aim hasbeen to collate relevant studies that have used a broad range of methods, so as to developa practitioner friendly resource. For this reason, we have made a considerable effort totrack down published and unpublished studies. The resource is intended to be accessiblein style, to make research available to practitioners, service users and policy makers.Reviews of any form of health promotion evidence are complex. The search termsused in search engines are not necessarily compatible with health promotion language.This problem is illustrated by Taub’s (2001) attempt to conduct a systematic review ofhealth education literature, which was thwarted by the breadth of the topic and searchlimitations, and because health promotion is a poorly indexed concept. Reviews ofmental health promotion interventions are thus also likely to be problematic, necessitatingresourceful search strategies to overcome the limitations of search indexes.In response to these limitations, we employed a range of strategies, including:• focusing initially on three specific areas of mental health promotion: social isolation,freedom from discrimination and violence, and access to economic resources• identifying systematic reviews of particular significance to the mental healthpromotion workforce• using an international expert committee to inform the review• actively exploring fields of relevance to mental health promotion as the evidencebased emerged.The following section outlines the method used to search for mental health promotioninterventions. Some material included in this section is relatively technical butnecessary to explain the approaches used to develop the resource and to describesome of the difficulties encountered.

Evidence-based mental health promotion resource115Selecting reviews for this resourceStudy selectionInitially, the search focused on systematic reviews of evidence. Where possible,searches were limited to ‘reviews’. While this approach may include narrative reviews,it is an effective search strategy. We also used a systematic review filter (see ‘Searchstrategy’) where relevant and where databases would allow this function.We included reviews if they:• contained primary research or were reviews of primary research• were published after 1998• focused on one or more of the review foci (social isolation, freedom fromdiscrimination and violence, and access to economic resources).We excluded reviews if they:• included poorly evaluated evidence• focused on treatment rather than prevention.We aimed to include the best available evidence. That is, we searched for systematicreviews that summarised good quality interventions. While randomised controlled trialsare the most rigorously evaluated interventions, they are not always the most appropriatestudy design for health promotion. In some cases, it may be unethical to randomisea study; in other cases, the cost of a randomised controlled study may be prohibitive.Observational studies have thus been more commonly conducted to address mentalhealth promotion. It is important to note that some systematic reviews do not includethese types of intervention. We were committed, therefore, to a multi-strategic searchingprocess that would identify the best available, most appropriate evidence.Internal study selection processA range of research groups have developed approaches to assess the quality ofqualitative systematic reviews. Elements of the work conducted by the Centers forDisease Control and Prevention, Rychetnik and Frommer (the National Public HealthPartnership) and Guyatt (the National Heart Foundation) were used to assess thequality of reviews included in this resource. This process was based on the criteriadeveloped by the Deakin University team who worked on a review of cardiovasculardisease and diabetes for the Department of Human Services (Garrard et al. 2004).The following three selection procedures were applied:1. Selection criteria were applied by two reviewers to reviews identified in the final search.2. Any discrepancies were discussed. Both criteria for inclusion/exclusion and qualitywere considered.3. Additional studies and reviews identified through grey literature or expert committeewere then considered as described above.

116 Evidence-based mental health promotion resourceExpert review panelA panel of experts was appointed to provide advice, identify published and unpublishedliterature and review a full draft of the resource. Each expert was consulted individuallyin late 2003 and asked to provide feedback on the following questions:• What body of evidence are you most familiar with?• Have you been involved in any systematic reviews?• What systematic reviews are you familiar with?• What grey literature sources are you familiar with?• What promising strategies not yet evaluated are you aware of?• Are you aware of any other innovative, successful interventions?Once we developed a final draft of the resource, we sent it to the experts andrepresentatives from VicHealth and the Department of Human Services to consider theevidence included and highlight gaps, based on their professional expertise.Data sourcesA critique of methods of systematic reviewing health education literature identifiedMedline, PsychInfo and EMBASE as the most appropriate data sources. These sources’level of indexing is more sophisticated than that of others, so more likely to identify theappropriate literature (Taub 2001). We searched using Medline and PsychInfo (becauseDeakin University has access to these databases) but also:• the Cochrane Library (including the Database of Abstracts of Reviews of Effectiveness)• CINAHL• APAIS-Health• AMI on Nursing and Allied Health.

Evidence-based mental health promotion resource117Interestingly, few of the included reviews were identified through the electronicdatabases. The Internet (and grey literature sources) were thus an invaluable tool.We relied heavily on Google, a well respected Internet search engine (www.google.com).We also accessed websites and databases to identify unpublished literature. Thesesources included:• the Centers for Disease Control and Prevention – www.thecommunityguide.org• the City of Hamilton’s Effective Public Health Practice Project –www.city.hamilton.on.ca• the Karolinska Institute – www.phs.ki.se/hprin/evidence• VicHealth – www.vichealth.vic.gov.au• the Australian Department of Health and Ageing – www.health.gov.au• the Victorian Department of Human Services – www.dhs.vic.gov.au• the Campbell Collaboration – www.campbellcollaboration.org/Search strategyWe conducted a separate search for each determinant of mental health, then addedthese terms to the health promotion/prevention terms and the study descriptor terms.This search strategy was an iterative process: several term categories were added as thereview process developed. This approach was necessary due to the limitations of theelectronic databases and indexing.

118 Evidence-based mental health promotion resourceThe terms listed in the following table are a combination of MeSH terms and text wordsused in the range of databases. Both truncation and boolean operators were appliedwhere relevant.CategorySocial connectedness/social isolationSearch termsSocial inclusionSocial isolationSocial justiceSocial alienationSocial environmentSocial involvementSocial perceptionSocial identificationSocial adjustmentSocial cohesionSocial capitalSocial distanceCivic engagementSelf determinationPersonal autonomySelf-concept (includes self-efficacy)HopelessnessSelf-esteemSelf-controlInequalitiesSocioeconomic factors

Evidence-based mental health promotion resource119Discrimination and violenceViolence(domestic violence, collective violence)TortureTrauma (and traumatic)AbuseDiscriminationPrejudiceGender bias (bias, gender)RacismSex biasSexismSocial discriminationSex discriminationEconomic participationWorkWorkplaceEmployment/unemploymentCareer mobilityOccupationEducationEducational statusHousingEconomicEconomic participationIncome

120 Evidence-based mental health promotion resourceFollowing this initial search, it became clear that we needed to address other issues,including suicide prevention and literacy (both mental health and educational literacy).As a result, the following additional search terms were included.CategoryMental health literacyLiteracy (educational)Suicide preventionSearch termsMental health literacyLiteracyAdult educationAdult literacySuicidePreventionAdditional search terms were used to identify reviews of effective mental healthpromotion interventions. They included ‘effective(ness)’, ‘success(ful)’, ‘mental healthpromotion’, ‘intervention(s)’, ‘implementation’ and ‘evaluation’. These were then enteredinto Internet search engines.Data extractionTables were designed to extract the most relevant data. They were used to identifykey emerging themes and to highlight study foci. Key headings included ‘Study’,‘Interventions’, ‘Outcome effects’, ‘Comments’ (related to quality/methodology,generalisability) and ‘Author recommendations’.LimitationsAs outlined, searching for evidence of intervention effectiveness is less well understoodin health promotion than in areas of clinical medicine. As a result, electronic databasesare not yet designed to search for this literature in an effective manner. The primaryissue is that subject headings for the social sciences are limited. While a subjectheading for ‘mental health’ is present in Medline, all subheadings relate to clinicalpsychology and psychiatry. As such, this is a large subject heading and may notassist in narrowing a search. At the time of writing even ‘health promotion’ has onlyone subheading: ‘healthy people programs’. That is, the subject headings do little toadequately describe the complexity of subjects in which we were most interested.From an indexing point of view, the breadth and depth of the social sciences make itdifficult to categorise material into index areas. Further, some databases do not providean indexing facility, so a reliance on text words is necessary. This process is timeconsuming and much more difficult to ensure a comprehensive review of the literatureis conducted. There is thus potential for systematic reviews to have been missed. Giventhe breadth and depth of the search, however, and the involvement of mental healthpromotion experts, we assume that the key reviews and promising interventions havebeen identified.This resource discusses important limitations related to the interventions described.Further details about the limitations of individual studies should be sought from theoriginal source.

Evidence-based mental health promotion resource121Appendix B: 10 health promotion action areasThe Ottawa Charter for Health Promotion (World Health Organisation 1986) and theJakarta Declaration for Health Promotion (World Health Organisation 1997) haveprovided 10 areas in which action should be taken to promote health.The Ottawa charter set out the first five action areas:1. Build healthy public policyHealth promotion goes beyond health care. It puts health on the agenda of policymakers in all sectors and at all levels, directing them to be aware of the healthconsequences of their decisions and to accept their responsibilities for health.Health promotion policy combines diverse but complementary approaches, includinglegislation, fiscal measures, taxation and organisational change. It is coordinated actionthat leads to health, income and social policies that foster greater equity. Joint actioncontributes to ensuring safer and healthier goods and services, healthier public servicesand cleaner, more enjoyable environments.Health promotion policy requires the identification of obstacles to the adoption of healthypublic policies in non-health sectors, and ways of removing those obstacles. The aimmust be to make the healthier choice the easier choice for policy makers as well.2. Create supportive environmentsOur societies are complex and interrelated, so health cannot be separated from othergoals. The inextricable links between people and their environment constitute thebasis for a socioecological approach to health. The overall guiding principle for theworld, nations, regions and communities alike is the need to encourage reciprocalmaintenance – that is, to take care of each other, our communities and our naturalenvironment. The conservation of natural resources throughout the world should beemphasised as a global responsibility.Changing patterns of life, work and leisure have a significant impact on health. Workand leisure should be a source of health for people. And the way in which societyorganises work should help create a healthy society. Health promotion generates livingand working conditions that are safe, stimulating, satisfying and enjoyable.Systematic assessment of the health impact of a rapidly changing environment– particularly in areas of technology, work, energy production and urbanisation – isessential and must be followed by action to ensure a positive benefit to public health.Any health promotion strategy must address the protection of the natural and builtenvironments and the conservation of natural resources.

122 Evidence-based mental health promotion resource3. Strengthen community actionHealth promotion works through concrete and effective community action in settingpriorities, making decisions, planning strategies and implementing them to achievebetter health. At the heart of this process is the empowerment of communities, wherebythey own and control their own endeavours and destinies.Community development draws on existing human and material resources in thecommunity to enhance self-help and social support, and to develop flexible systems forstrengthening public participation and direction of health matters. This process requiresfull and continual access to information, learning opportunities for health, and fundingsupport.4. Develop personal skillsHealth promotion supports personal and social development by providing information,educating about health and enhancing life skills. By doing so, it increases the optionsavailable to people to exercise more control over their own health and environments,and to make choices conducive to health.Enabling people to learn throughout life, to prepare themselves for all of its stagesand to cope with chronic illness and injuries is essential. This enablement has to befacilitated in school, home, work and community settings. Action is required througheducational, professional, commercial and voluntary bodies, and within the institutionsthemselves.5. Re-orient health services towards primary health careIndividuals, community groups, health professionals, health service institutions andgovernments share the responsibility for health promotion in health services. They mustwork together towards a health care system that contributes to the pursuit of health.The role of the health sector must move increasingly in a health promotion direction,beyond its responsibility for providing clinical and curative services. Health servicesalso need to embrace an expanded mandate that is sensitive and respects culturalneeds. This mandate should support the needs of individuals and communities for ahealthier life, and open channels between the health sector and broader social, political,economic and physical environments.

Evidence-based mental health promotion resource123The Jakarta declaration added the following action areas:6. Promote social responsibility for healthPolicies and practices should be pursued that: avoid harming the health of otherindividuals; protect the environment and ensure sustainable use of resources; restrictproduction and trade in inherently harmful goods and substances; safeguard boththe citizen in the marketplace and the individual in the workplace; and include equityfocused health impact assessments as an integral part of policy development7. Increase investments for health development to address health and social inequitiesIncreasing investment for health development requires a truly multi-sectoral approach,including additional resources to education and housing as well as the health sector.Investments for health should reflect the need to address health and social inequities,focusing on groups such as women, children, older people, Indigenous people, those inpoverty and marginalised populations.8. Consolidate and expand partnerships for healthHealth promotion requires health and social development partnerships among thedifferent sectors at all levels of governance and society. Existing partnerships need tobe strengthened and the potential for new partnerships must be explored. Partnershipsoffer mutual benefit for health through the sharing of expertise, skills and resources.9. Strengthen communities and increase community capacity to empower theindividualKey strategies at a community level are:• strengthening advocacy through community action, particularly through groupsorganised by women• enabling communities and individuals to take control over their health andenvironment through education and empowerment• building alliances for health and supportive environments to strengthen thecooperation between health and environmental campaigns and strategies• mediating between conflicting interests in society to ensure equitable access tosupportive environments for health• improving the capacity of communities for health promotion, which requires practicaleducation, leadership training, and access to resources• empowering individuals, which demands more consistent, reliable access to thedecision-making process and the skills and knowledge essential to effect change• re-orienting health services, which requires stronger attention to health researchand changes in professional education and training. This must lead to a changeof attitude and organisation of health services, refocusing on the total needs of theindividual as a whole person.

124 Evidence-based mental health promotion resource10. Secure an infrastructure for health promotionGovernments are the stewards of the health of populations. They have a responsibilityto establish a strong infrastructure for public health that includes a funded commitmentto health promotion. ‘Settings for health’ represent the organisational base of theinfrastructure required for health promotion. New health challenges mean that healthand non-health organisations need to be able to respond effectively, so new anddiverse networks need to be created to achieve intersectoral collaboration. Trainingin, and practice of, local leadership skills should be encouraged to support healthpromotion activities.